GW1-2023-02817_Well Construction - GW1_20230420

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WELL CONSTRUCTION RECO (GW 11 • ForinternalUse Only:
1.Well Contrac#or•Iuforma on: •
• '14.WATER ZONES
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Well Contractor am� FROM TO DESCRIPTION
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5 • o a• Aoo ft
f. ft.
NC a C�on�6a�eto}r�Ceymficaatioa�Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Gable)
•
� �`�✓l/I / ) ./Y� FROM TO DIAMETER THICKNESS MATERIAL
Company Name. ft ft in.
V V (a 16.INNER CASING.OR TUBING(geothermal dosed-loop) •
2.Well Construction Permit#: V O l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(l e.WC,Conn%,State,Variance,eta) +I ft X 5 ft 5 7h! m• �I.C 6‘
K�
3.Well Use(check well arse): •
ft. ft. in- •
Water Supply Well: • A7.SCREEN
❑A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn ❑MtuticipaUpublic f ft. fa.
❑Geothermal(Heating/Cooling Supply) dential Water Supply(single)
ft ft. hi.*
❑lndustrial/Commercial / idential'Water Supply(shared) •
18.GROUT
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOU:PT
Non-Water Supply Well: D ft Z 3 ft
• ❑Monitoring ❑Recove• ry R `� (
ej Injection Well: O r l cu l
• ' ❑A uiferRech a it ft /�/:CV°
' r�''
q � ❑GmundwaterRemediation
❑Aquifer Storage and Recovery • ❑g 19.SAND/GRAVEL PACK(if applicable) •
alinityBarrier FROM TO MATERIAL nine. METHOD
❑Aquifer Test ❑StormwaterDrainage I ft ft•
❑Experimental Technology OSubsidence Control • ft. ft
• ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO ft : DESCRIPTION(color.hardness,soflreek type,grain size,cte.)
4.Date Well(s)Completed: ''-- -2-3 Well ID# ft. •ft
Sa.Well Location: ft • ft •
it-1- S h - . tt ft- t.----,:-
• - •;- A_
• Fa' ty/Owner Name Facility ID#(if applicable) ft ft
- L�Q�U// = S11 AYnt:e. AA ,.••. • '''ft. ft APR 21
Physical and Zip
_all .1X1`-) 21.RE MARKSI 'Y v,D ,County . Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) '
t 17 • 22.Certification:
�L 'N 81 1, ' 38 w
.6.Is(are)the well(s): [ ermaneut• or ❑Temporary 2 ' gnauue o•'i'"`'tc.e•i �� ��` �`,_2�
/ R !J oQ Si t ' ell onhactor Date
B
5ChCt hat Wwas e ) sthaco7.Is this a repair toan existing well• ❑Yes or No 1ANCAC0 'O100o iSANC 02C.0200ellConstructonStondardanc py
!phis is a repair,fill out brown well commotion information and plain the nature of the of this record has been provided to the well owner.'repair under#21 remarks section or on the back ofthis form.
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 Rdniarks Box).You may also attach additional pages ifnecessary.
drilled
11 24.SUBMITTAL INSTRUCTIONS ' '
9.Total well depth below land surface: ..T� (ft)
For multiple wells list all depths lfd/fferent(caotrrp/a_g 0'and2 ploo9 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of,casing: r� • (ft) 24a._For All Wells: Original form to Division of Water Resources
Ifwater level is above eosing;use"+"I�` ` D Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • (DWR),
)'
11-Borehole diameter. Ib •(n.) 24b.For Injection'Wells:Copy to DWR,Underground
A Program,1636 MSC,Raleigh,NC 27699-1636 Injection Control(IUC)
12.Wen constructionmethod: R O-I au .,_ Ile"(i a auger,rosary,able,direetpush,etc.) I 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
• county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: •
n 24d..For Water Wells producing over 100,000 GPI:Copy to DWR,CCPCUA
13a.Yield(gpm) l 5 Method of test l_.1 ,• Permit Program,1611 MSC,Raleigh,NC 27699-1611.
0 ,t •
13b.Disinfection type: ��' Amount ' !y
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•'Form GW-1 N��h r.....a:-:n��__ . .... . I