GW1-2023-02792_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD(GW-1) For-Internal Use Only:
I.eWell Contractor Information:
FIECEIVED We WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
7� APR 10 2023 3-6 It. /5-5 ft. Pe r
ft. ft.
NC Well Contractor Certification Number
q NC �E(/®�� 15.OUTER CASING for multi-cased wells OR LiNER if a livable
FROM DIAMETER THICKNESS MATERIAL
£�(�rt�tr�lOffir:� ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.Counq..Slate,V(piance,etc.) ® fL ft. in. SC./ O 1 V
3,Well Use(check well use): ft. ft. in. 7 '
Water Supply Well 17.SCREEN
FROM TO DL+MF.TER SLOT.917E THfICK�NEf," MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(i-1 cat ing/Cooling Supply) ❑Residential Water Supply JrI ft S S ft in 'D f v S V L
pp y(single) ft. ft. in. --'—
❑Industrial/Connmercial ❑Residential Water Supply(shared)
18.GROUT
❑liTi ation ❑Wei is> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
12W-oritoring ❑Recovery ft. tt. p,vere /
Injection Well:❑A uifer Recharge ❑Groundwtter Rcntediation ft. et
hrl^e�vi �-IGC�
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if a Hcable
FROM TO MATERIAL F,a1PLACENIENT METHOD
❑Aquifer Test ❑StormvaterDrainage ft. �SE R. _ VC r_-tZ// S/Ow ps.r L NeT
—i Pr' .vet
❑F,xperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG lattach additional sheets if necessnry
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCRII TION(color,hardness solUrock c, ram size,�rc:�-
0 ft. S„ ft.
4.Date Well(s)Completed: - �-•� Well ID#�!' ��- ft. ft. p
Sa.Well Location:
ft. ft. --- —_ —-- --—-i Facility/Owner Name Facility ID/1(if applicable) ft. ft.
,U T/r e e f _ y
Physical Address.City.and Zip. ft. ft. _...a_
C r c V e,,L, Z _ p O t/( 21.REMARKS — —
County Parcel Identification No.(PiN) t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/loog is sufficient) 22.Certification:
35 11gS'D6, N 7 p2-y9lG l
w Ge/ e{/ 71 .-�,��C
6.is(are)the well(s): l941nanent or ❑Temporary Signature of Certified Well Contractor Date
Ur signing thisJorin,1 hereby vend&that tint n ell(s)was(were)I-onc7rucled in acc•at du
7.Is this a repair to an existing well: ❑Yes or M?ro /SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well.Construction Standards and drat a;zj_r
Jfthis is a repair,Jill alit knonn well constr,ec/ion hilorntalion lard esplain thr nature afthe o/7his record has been provided to the well owner.
repair under 021 rentarks section at-an the bark of this Joan.
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 1 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: _ft.)
Frn•umlliple wells list all depths ifdfyerenl(erangt/e-3@200'card 2(_i)i00j ( Submit this GW-1 within 30 days of well completion per the following:
lU.Static water level below top of casing: 3. 46 — ft 24a. For All Wells: Original form to Division of Water Rcsourcati (DWR).if water level is above casing,use"+" _ -- ( ) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: Copy to DWR, Underground Injection Coutroi(IUC)
Program. 1636 MSC:,Raleigh,NC 27699-1636
.Well construction method: eu q e I—
(i.e. For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.i.e.auger,rota •---' pp ti'
g 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,C('PCl)A
13a.Yield m Method o1'test Permit Program, 16l) MSC,Ralcigh,NC 27699-161 1
(gP )
13b.Disinfection type: Amount:
Pam,f:W_1 AL..�1.f`-...I:....fl-....n.......,..{'C....:...............I ll....l:... n:..:..:......f,v....,_o......:....;.. n...��.,.1/._6-llli4