GW1-2023-02791_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information ®
: 1 REOEIVE
V //n i CLM /)i/n 1) C2►'/ 14.WATER ZONES
Well Contractor Name APR Atl 7fiy�_g FROM I TO I DESCRIPTION
V� Gi1GY 3, rt. ft.
p• ix_.,�q, ft. ft.
NC Well Contractor Certification Number m c q�, 't 15.OUTER CASING for multi-cased wells OR LINER if a Ilcable
FROM TO DIAMETER THICKNESS MATERIAL
ft. it. I in.
Company Name
16.INNER CASING OR TUBING reother Ial closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC.County,State,Variance,etc.) ft. L �' ft. 2 in.
3.Well Use(check well use): ft. ft. J in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZEJ THICKNESS I MATERIAL
[]Agricultural ❑Municipal/Pubhc ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
Non-Water Supply Well: It. - S ft. 130.v/v.v,. �� �•�� cz�
ildtClonitoring ❑Recovery 0 ft, 3 ft C F.vc"e e L rC v i,l
Injection Well: tt, ft.
❑Aquifer Recharge ❑Groundwater Renrediation
19.SAND/GRAVEL PACK if a Hcablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage -�' ft. �L ft. / .-
S
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other•(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,sowreck rain size etc.
© rr. j S ft.
+. ac,.vcC �,� 1�;c rech
4.Date Well(s)Completed: _2,3 Well w# PI)i t%{.1 rt, it. y /
(`f/ -S ct.v rl� I r�
!o i.v/V
5a.Well Location: ft. ft.
ENE E C CJx ,
�M-,d ..J,t eS Alc b 4©:S ZQf 83Z
Facility/Owner Name Facility iD#(if applicable) ft. ft.
// 2 /� sf ree_t, 13 r: Z t?�o ✓ Z� ./�% fr. rt. e 2023
Physical Address.City,and Zip !! ft. ft.
C re-i/e n- r~ ��t -C O 21.REMARKS u'e a 6 it r
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one[at/long is sufficient) 22.Certification:
3s', 117 .S-r ; N `'77. 6 2 IS 16 W ' �' �' :7 /
6.Is(are)the well(s): ®'Permanent or ❑Temporary Signature of Certified Well Contractor r.1 Date
By signing this form,l hereby certify that the nellH'ivas(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or 124o 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction igforntatiat and explain the nature ofthe of this record has been provided to the wall o,mer.
repair tender#21 renmrks section a•on the back ofihic fain.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �f', (ft.) Submit this GW-1 within 30 days of well completion per the following:
ror multiple,yells list all depths tfdierent(example-3@200'and 2@100)
10.Static water level below top of casing: 3. L (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If crater level is above casing,use"+" information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: O (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A t)I a e- 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d,For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Amount:
i
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resource's i Revised 6.6-2018
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