GW1-2023-02818_Well Construction - GW1_20230420

33 6 -51 756•2,
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WELL CONSTRUCTION RECO (GW-1) For Internal Use Only: .
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• 1.Welle Contractor.Inff ormation:
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�J•M • 1 V '14.WATER ZONES
Well ConhaetorName /FROM TO DESCRIPrlON
i. '�'°� 5 • !g'v ft.. 3 f ft •
ft. ft.
C Well Contractor Certificationjumber 15.OUTER CASING(for multi-cased wells)OR LINER(ifap liable)
Pt' Qjv FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
• 2.Well Construction Permit#: 0 -[�]i f((3 FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,eta .j) -C ft / & 7, in. 7-hick.
C dD ez--
3.Well Use(check well use): ft ft. in.
Water Supply Well: 47.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• ❑Agricultural •❑Municipal/Public ft _ ft. .- in.
❑Geothermal(Heating/Cooling Supply) -residential Water Supply(single) ft ft ia..
❑lndustriaiiCommercial ❑Residential•Water Supply(shared) 18.GROUT •
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FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation ❑Wells>100,000 GPD
Non-Water Supply Well: 0 ft Z3 ft t-•
• ❑Monitoring ❑Recove � M t x �,Q
`• ry ft. ft.ft �t^k( e 17 Ll/w�r,AilInjection Well:
• • ❑Aquifer Recharge ❑GroundwaterRemediation 1
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) •
FROM TO MATERIAL EMPLACEMENTMEtHOD
❑Aquifer Test ❑Stornwater Drainage ft. ft
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❑Experimental Technology ❑Subsidence 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 DESCRIPTION(color,hardness,soil/reek type,min doe eta)
ft. ft.
4.Date Well(s) ID
Completed: 3"31'13 Well #. •
ft. ft
Sa Well Location: ft. ft r_
• Factiity/Owner Name Facility ED#(if applicable) ft ft 1
�ira i, ;11 IAin,t.(�►,v /d • . . . APR n ?���
"ft ft �.,
Physicaliress.City,and Zip ft MI6,"rt-=<V`l _.`
21.REMARKSI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
- (if well field,one lat/long is sufficient) 22.Ce ti 1
3L' j ' ` l N �( ' 55 ' ?.q . W Qco ,
6.Is(are)the walks): ermanent or ❑Temporary i T iJ O -1SignatureICethflaf.We]1Conhictor• Da .
By signing this form,Thereby centfy that thewell(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or 1 No 1SANC,AC 02C:0100 or IS4 NCAC 02C.0200 Well Construction Standards and that a copy
this is a repair,fill out brown well construction information�/d�lain the nature of the of this record has been provided to the well owner.
If
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'repair under#21 remarks section or on the back of this 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 Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMLTTAL INSTRUCTIONS '
9.Total well depth below land surface: (ft)
For multiple wells list all depths If different(example-3Q200'and 2(a)100� Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top S casing: to • (ft) 24a. For All Wells: Original'form to Division of Water Resources Ifwater level is above caring use_ ; Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • (DWR),
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11.Borehole diameter: tfrs/8 .(in-) 24b.For Injection Wells:Copy to DWIt,Underground Injection Control(ILIC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �a1a as` -AY....
(i e.auger,rotary,cable,direct etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the '
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county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: •
• 24d.For Water Wells producing cing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) • _co Method of test: ��� Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: //!// c c-s.r - u t
//J{ Amount: