GW1-2023-02794_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD GW-i
For•Internal Use Only:
I.Well Contractor Information:
z1101 1l cv , //• -A Pr(y IIECEIVED
Name
Well Comrtfctot I4.WATER ZONES
FROM TO DESCRIPTION
,3 * 77 APR 02023 3,v/ ft. !s ft.
C Well Contractor Certification Number
ft. ft.
tsC DEQ/DWfj 15.OUTER CASING for multi-eased wells OR LINER if a licable
—�E'frs t�tit/;`rdw y1.Ie,,�&l C011`afat®ffiC@ FROM TO DIAMETER THICKNESS
MATERIAL
Company Name ft• ft. in.
2.Well Construction Permit#: 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER TIIICKNFSS MATERIAL
1,isl all appl(cable well cats0vrctlom permits(i.e.U/C.Crnau)�.Scale,Variance,etc.) O ff. ft. n.
—� i
3.Well Use(check well use):ill , ft. ft. in.
Water Supply Well: 17.SCREEN
❑Agrictiltttml FROM TO DIAMETER SLOT SIZE THIClG�ESS M1tATER1AL
❑Municipal/Public❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) L O �C{1 V D pvc
❑lndustrial/Commercial R• R. In.
❑Residential Water Supply(shared)
FOAquiferStorageandRecovery
ation 19.GROUT
❑Wells> 100,000 GPD FROM TO _
Nonafel'Supply Well: MATERIAL EMPLACEMENT METHOD&AMOUNT
toring ❑Recove 3 ft- it -�,' PC 11ei 5 L•rrc ,Fy(( /��✓
on Well: ry
fer Recharge ❑Grougdwater Remediation ft ft.
w
❑Salinity Barrier 19.SAND/GRAVEL PACK ifoplincuble
FROM TO MATERIAL EMPLACEMENT 5 ETHOD
❑AquiferTest ❑StonmvaterDrainage ft. rt, Gt�,•rtZ ty
❑ExperimentalTechnolo
Technology ❑Subsidence Conit•ol tt. iL
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heat ing/Coohng Return) ❑Other(explain under#21 Remarks) 20.DRILLING LOG attach additloaal sheers if necessary _
FROM1f fr. TO DFCRIPTION color hardnc soil
b I Groin ehc,cfc.)
j 5- rr.
4.Date Well(s)Completed: ft. !•C L4,
Well iD# �f 6cl—l/ `;
C�`��'—�t� G
So.Well Location:
«,
/Location: ft. ft
d V--CC- -
Factlity/Owner Name racility ID#(ifapplicable) ft• ft. _
rt. ft.
Physical Address,City,and Zip ft ft o e, l'ZJ� _J
' 3
C r a y fI 2 — 6 o f -- 0 p L( 2I.REMARKS —
Parcel identification No. PiN
5b.Latitude and longitude in degrees/inillutes/seconds or decimal degrees:
(ifwcll field,one Iavlong is sumcical)
s � � �,�D b IfC16.
22.Certification: ,
ermanent or ❑Temporary Signature of Certified Well Contactor
6.is(are)the well(s): Qi' ' pale
By signing thisforn+,1 hereby cerq).lltat the well(s)7.Is thus a repair to an existing weu: oats(xerel eonsuut[ed in accordance with
[]Yes or &N,0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lyell lfthiv it a repair,fill out known nr/1 cm"I"Ifeliar infarrrmtion and arplain/he nature ajthe g0his record has beenprovided to the well ouvier Consmvc Stmrdnrdr and that a evil•
cun.repair under#21 rtwrarks section or an the back oflhi,.forvn.
23.Site diagram or additional well details:
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well consh•tiction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL 1TNSTRUCTIONS
9.Total well depth below land surface: 1S (ft)
For nadtiple irellc lief all depths ifdi(frrera(ecanrlde-3 rci 200'arc 12 a 100) Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3- (ft.) 24a. For All Wells: Ori4inal form to Division of Water Resourcel; (DWR),
q'ivater level is above casing,urc ,+• Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: O (in.) 24b. For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Program, 1636 MSC,Raleigh,NC 27699-1636
_ � ✓�j P �
(i.e.Huger,romr}t cable,direct push,etc.) 24c.For Water Su 1 and Open-Loop Geothermal Return Wells;Copy to the
county,environmental health department of t e county where installed
FOR WATER SUPPLY WELLS ONLY:
24d,For Water Wells roducin over 100 000 GPD: Copy to DWR,CCPCUA
fgPm) Method of test:
13a.Yield Permit Program, 1611 MSC,Ra eigh,NC 27699-1611
13b.Disinfection type: Aniouot: -
i
rom rw-i _