GW1-2023-02830_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD (GW-D) For Internal Use Only:
1.Well Contractor Information:
�1^\ I
`lt"\ Q0 SleLA 14.WATER ZONES
\yell Commctor Name FROM f0 DESCRIPTION
1 �� fL 1 �i Q ft• �i 17 � W1
5 L"� ft. I n.
NC Well Contractor Certification Number 15.OUTER CASING(fnr multi-cased wells)OR LLVER(if applicable)
ll \ FROST TO DUME'reR TlIICRNESS \i,TERIAL
A1/l (°, ff. in. D� D
Company Name
16. R CASING OR TUBING(geothermal closed-lo p) J ✓
2. 7 Well Construction Permit 4: �,S 3 INNER
TO DLASIETER I TIIICK_N'ESS I \IATERLIL
List all applicable urll construction pemnits Ct_e.UiC.County,State.Variance.etc.) It. n. in.
3.Well Use(check well use): ft- ft.
Water Supply Well: 17 SCREEN
BROV TO DL•L11E LIJ I SLOTSIZE TIIICFC\F&s MATERLIL
❑Agricultural ❑Municipal/Public It_ IL in.
❑Geothemlal(Healing/Cooling Supply) t9Residenlial Water Supply(single) p, tt in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100.000GPD FROM TO MATERLILL ESIPLACF-%M,T31Ef1tOD&,t1i01Nr
Non-Water Supply Well: ©
❑Monitoring ❑Recovery 3 ft- P-0 ft. °-
Injection Well; fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
FlAquifer Storageand Recovery ❑Salinity Barrier FROM TO \L•1TERIAL E.\IPL&CEAUXI'IIETIIOD
❑Aquifer Test ❑ m SlorwaterDrainage ft. rt• t
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Healing(Cooling Ketum) ❑Other(explain under r21 Remad ) FROM TO DESCRIPTION(co m
olclor.hdacss,soilfrock type.grain size.etc.)
ft
l0 ft. S� J V/\ ©t.
4.Date Well(s)Completed:0 Well ID$-_7r�S 3-3 �p n. ft_ E2e�
- - ft. l ft. \.
Well Location: L C v G-
Pvy ft.. it.
rc. ft_
Facility/Owner-Natne Facility iDil(ifapplirablz)
APR
2 020123
Physical Address,City,and Zip fL ft-
�O�L� ���� �© 2-9
County
r.t;•;•.�:'",,gyp...
County ® Parcel Identification No_(PIN)
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(ifcvell field.one lat/long is sufficient) 22.Certir, ti n-
N07 II wk ti
6.is(are)the well(s): EAPermanent or ❑1i'emporary Si unaturc o Ccrtifie \'ell Contract Date
13rs•••ping this,/ornn.1/•^•:r{t �ert(fi that tiff irel((s)-G'c fn et_e)constrrtcrrd_i•t nrrnrdmex��.itF
.►a�+t, rain h r. .» . ,�..,
t.IS tfus a repair fo an exis�:rtng well: Dyes or �o 02C.011lU or di.a A'CdC(12C.020(1 Hell Car.0 urt(au Standards and that a copy
fade is a repair ill out htotni trell construction information and explain the nature of the of•this record has been provided to the hell on•rter.
repair under ri31 remarks section or on the back of7hic lbrm.
23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having file same You may use the back of this page to provide additional well construction info
construction,onl�1 GW-I is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
unlied: 24.SUBMIT rAl,INSTRUCTIONS
r
9.Total well depth below land surface: 15 (ft.) Submit this G\V-1 within 30 days of well completion per the following:
For multiple trells list all depths ifdi(ferent(example-3@200'anel 2 ir?100') Y P P o•
oZ 6 24a. For All Wells: Original form to Division of Rater Resources (DWR),
10.Static water level below top of casing: (fk) Information Processing Unit, 1617 VISC,Raleigh,NC.27699-1617
If uvier level is above casing.use-l `
11.Borehole diameter: `� (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(HJC)
c�` I Program. 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 R- 1W��-R`1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.anger,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 DF'VR,CCPCUA
\ Permit Program, 1611 MSC,Raleigh,iNtC 27699-1 6 1 1
13a.Yield(gpm) 1 © r, tl'iethod of test: 1
13b.Disinfection type:rl C'Wo VItf-Q_Amount: '` O - -
Fong G%Y-1 North Carolina Department of L-nviroam ntal Quality-Division of"Water Resources Revised 6-6-201 S