GW1-2023-02790_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD- G-__�
t t CD For Internal Use Only:
1.Well Contractor Information:
02023
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
3E 76 ,• NC DEQ/DVIt'R �.6 ft• /S' H. �• nn
NC Well Contractor Certification Number Central Office tf ft.
1S.OUT CASING for
multl-cased
FROM Ilnble
ll1AMETER THICKNESS
Company Name ft. MATERIAL
'7� ft.
2.Well Construction Permit#:�/C. t r•6-6 A ']/`�)l�7G�Sj 16.INNER CASING ia.OR TUBING eothermal closed-loo
List all applicable well construction pennrts( U/C.Caongr yut,•ats FROp1 ff TO DIAMETER THICKNESS
MATERIAL
ft,3.Well Use in.
(check well use): fL tt in
Water Supply Wep:
17.SCREEN
❑agrlCUlflrral ❑Municipal/Public FROM TO DIAMETER SLOT SIZE THICtG�EeS MATERIAL
❑Geothermal(Heating/Cooling Supply) ft ft, in.
g PP Y) ❑Residential Water Supply(single)
❑IndusMaUCommercial ❑Residential Water Supply(shared)
ft ft In.
❑lF ation PP y( 18.GROUT
❑Wells> 100,000 GPD FROM TO Non-Water$Upp)y Well: MATERIAL- EMPLACEMENT 51ETHOD&AMOUNT
❑Monitoring ft ft.
Injection Well: ❑Recovery
ft. fL
❑Aquifer Recharge [�fl%iroundwater Remediation ft• ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if a llcablc
❑AquiterTest FROM To MATERIAL EMPLACEMENTMETHOD
❑Stormwater Drainage
❑Fxperimenlal Technology ❑Subsidence Contt'ol
❑Geothermal(Closed Loop) ff ft.
❑Tracer 20.DRILLING LOG attach additional heets If necessa
❑Geothermal(Heating/Cooling Refute) ❑Other'(explain treader#21 Remarks) FROM TO DFCIM7s N rotor,hardness salVruck c rain size,cars-
-----
4.Date Well(s)Completed / / 'Z Well iD# �-W'-Q r,,C�
ft
511.Well Location: C 1 e Shc NCQ — ( ter-/1 /uct�iv
ff. ft.
Cl1t�m;�r;�5�.1eJ fY'�'DvU3�vI37 �:.
Facility/Owner Name
Facility ID4(ifapplicable) ft. ft. —
112-10 6 .5-frCP-1- A _ ...
Physical Address,Ci y,and Zip
l f--I VCR L tr. It.
--L�r:>� —(,�C� 1 21.REMARKS ������,y - .--
County p
Parcel Identification No.(PiN) �� P G t' a/ p,:.V tS CtiKi�eA ArL
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 11 n / C �• ��
(if well field,one IaVlong is su�cicaU) �t���C T �" `t-rh �PC�i..�I., -
15
� � •� � 22.Certification:
11_2 Q N " / 7 �z y �l�
6.is(are)the well(s): ❑Permanent or ae'nemporary �J -3 Z C.t 2-
Signalure of Certified Well Contractor
/� i...s�. Date -
7.is this a repair to an existing well ❑Yes or La})Qo ki'sigiringthisforni,lbereb}•cer/ij•drat dre nell(.r);vas(were)0 a) roI trcrerl in accordance with
01liv iv a repair;Jill out known n ell consnvrction information and erplain the narrrre ofthe 90111 record has been protirded w I rOn e!!o20D'Ye/l Coostructlon Strrndnrt/ and dint a c gr
repair under ft2l remarks section or nit the back of ihivtoter.
8.For Ceoprobc/DPT or Closed-Loop Geothermal Wells having23•Site diagram or additional well details:
construction,Only I GW I is needed. Indicate TOTAL NUMBER of the
(add'See OvefYou may use thn Remarks Box).You may also attae back of this page to provide ch additional pageitional well s iif necessf y.
drilled:
9.Total well depth below land surface: 24•SUBMITTAL INSTRUCTIONS
Fernier/tip/e is list all depdcc i/'diJ%rent(e.ranip/e-3@200'and 2@I00) (ft) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: -3- CI (ft) "24a. For All Wells: Ori4inal form to Division of Water Resourcce (DWR),
!/';voter level is above cocing,rrrc^+' lnfonnation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: p Z 5 liar) 24b.For Injection Wells: Copy to DWR, Underground injection Control(IUC)
p Program, 1.636 MSC,Raleigh,NC 27699-1636 12.Well construction method: �%r PC fi / us�'1
(i.e.Huger,rotary,cable,direct posh,etc.) 24e.For Water Supply and ODen-Loop Geothermal Return Wells Copy to the
county environmental health department of the coup where installed FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells DrOducine over 100.000 GPD• Copy to DWR,CCPCl1A
139.Yield(gpm) Method of test Permit Progmm, 1611 MSC,Raleigh,NC 27699-1611
13b,Disinfection type: Amount:
Form GW-i