GW1-2023-02845_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well ConfinetoName FROM TO DESCRIPTION
3541 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if ap licable)
(1 1� FROb7 To DIAM R THICKNESS MA IAL
V
Company Name o ` y a
16. t R CASIN OR 4TUBING Geothermal closed-loo )
2.Well Construction Permit#: �'1 R t{ f i FROM TO DIAMETER THICKNESS I 3UTERIAL
List all applicable irell construction perorits rile.UIC,County,State, 4ariance,e1c.) ft. ft. in.
3.Well Use(check well use). Ct ft. in.
Water Supply Well: 17.SCREEN
FROM TO DL►31= SLOT SIZE TRICIL'NESS 31ATFRiai
❑Agricultural ❑Municipal(Ptlblic tt ft. in.
❑Geothermal(Heating/Cooling Supply) XRcsidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑biigation 0Wells>100.000GPD FROM TO M,%TERLII E3 LP LACE3IE.N'T3fET1I0D&,%mouNr
Non-Water Supply Well: D R_ -3
❑Monitoring ❑Recovery ft © ft.
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier 11RO31 To I MATERIAL Ei l I_&CEMENf METROD
❑Aquifer Test ❑Stormwater-Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Heating/Cooling R 1RO37 -TO DESCRIPTION(color,hardness,soil/rack type.grain size,etc.)
Return) []Other(explain under#(2�1 L Remarks) R. �� ft.
4.Date Well(s)Completed:` `fT' Well ID# �J 1, �O Ct.' Ct ,N _
5©
Sa.Well Location: �it. �5 rr. 0,
ns Inc,
Facility/OwnerNamc Facility iDll(ifapplicable) R. ft.
ft: = ft J 3-
E'hysical Address,Ciq{{�.and Zip it ,�•,;,.,,,..,� ;�r-+.�;.-.,;-
Fla 7V U'`.
21.RE1IARKS
County p_ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tatllong is sufficient) r 22 a tification• -
O N � � � 3� E25 J W
D
6.Is(are)the well(s): Xpermanent or ❑Temporary Signs a of' i d W 1 oniractor Date
At,signing this form.l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or '�&o 15A NCAC 02C.0100 or 15A ArCAC 02C.0200 A'ell Construction Standards and that a copy
if thiv is a repair,fill out kwoim well construction it formation and explain tire nature of the of7lris record has been provided to the well omrer.
repair tinder 921 remark section or on the back of this form.
23.Site diagram or additional well details:
S.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 I GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
dnlled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C� S (ft.)
ror multiple wells list all depths if different(e.Yainple-3@200'and 2@ 100') Submit this GW-1 within 30 days of well completion per the following:
D (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
fftwter level is shove casing,use i Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If " '
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
n f� Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e_-auger,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 CCPCUA
13a.Yield(gpm) Method of test:
`/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:k OVA�OrG Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018