GW1-2023-02953_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
S o poble_
�t i14:AN'TER
--+ FROM TO DESCRIPTION`
Well Contractor Name ft. fib ft.
NC Well Contractor Certification Number 515rO1J klrR CASING;for indlhast'twells bR LZNER?'rf a "livable Y .. i
FROM TO DIAMETER THICKNESS MATERIAL
ob�Q. P V�n ft. ft. in. 0 !� I
CompahyName 1G;iFIN$R CAS NG i3RrT[kBIBIG: `eotherni"al closed'.1Dii r ..s,_;,>.
2.Well Construction Permit#: a�- 000 P o FROM TO DIAMETER THICKNESS MATERLAL
List all applicable well construction pernrits ri.e.UIC,Couno,,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft rn
Water Supply Well: FROM TO V DIAMETER SLOT SIZE Yi THICKNESS r; MATERIAL`
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) JResidential Water Supply(single) ft. ft. 'In,
❑Industrial/Commercial ❑Residential Water Supply(shared) Ro51Tt,;k;:4-
❑Irri ation ❑Welis>100,000 GPD FROM TO MATERIAL y EMPLACEMENT METHODt&AMOUNT-
Non-Water Supply Well:
❑Monitoring ❑Recovery it. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
!19 SANAJGELPAEK tf>a licabie € x .�.
❑Aquifer Storage and Recovery ❑Salinity Bairier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage IL ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2b:.'-DRILI II+JGt GG attach addttdiai s7t�ets;i!`neoessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soft/rock a rain size,etc.)
4.Date Well(s)Completed:a 1 1- We11ID# !� ft. b ft. e
5a.Well Location: . ft- 9-00
C1 ft. _
Facility/Owner Name Facility ID#(if applicable) ft. ft.
)( uU 11►J self 1N 1�0bQ y'a ft. ft.
Physical Address,CCiM and Zip^—� J ft. it
Y--'I�� ,l •o-x3r.'�i'MAIZXCSci: �.,.r...:�' �,r.:3�� ' ,l h;'�s.. r -: ' ,��.:.;.;
County Parcel Identification No.(PIN) DV1Q1 BOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certif lion:
N W 3_ j,-y3
6.Is(are)the well(s)• 4ermanent or ❑Temporary Signature Certified Well Contractor Date
_l By signing this for•m,1 hereby certify that the wells)was(were)const acted in accordance with
7.Is this a repair to an existing well: ❑Yes or i4 15A NCAC 02C•0100 or ISA NCAC 01C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
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-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 INSTRUCTIONS
9.Total well depth below land surface: a l/o (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: )® (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water•level is above casing,use
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(RJC)
`� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r6 I b�� 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
Permit Program,1611 MSC,Raleigh,•NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Yl Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018