GW1-2023-02966_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information:
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FROM TO DESCRIPTION
Well Contractor Name A ft. 5'( it. 11
ft
NC Well Contractor Certification bIm cr nn 1 rplt$vO1J kt1 R @z1SI11G foc mul]h caS2d�wglls l)R 1IjYER tLa lic"26le
C u o o Vv lrbyq P7 FROM TO DLCMETER THICKNESS MATE RLAL
w J it ft. in. ►/ (�
CompanyNatne r� Q �j ii1GsIP11VE1t:CS LYG,dR?T[F� (� �6iti'eruisl eloSed?T0o �
3-11
2.Well Construction Permit#: d-O L a FROM TO DIAMETER THICKNESS MATERLAL
List all applicable well construction permits(e.UIC,Counq,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. n•
.T 4'.':SVREE4,�)`.:FVt v'�f:...�i1L xYi<M,L•�:`{.J.•,?.,iti�.nP.l+-5���+•Y. kS4,�+.Y(_l 'nP:J'.-�:�:�f`.'ti�-'+:;
Water Supply Well: FROM TO DLUMETER SLOT SIZE THICKNES I MATERIAL
❑Agricultural lesidential
unicipal/Public ft. it, in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft tt tn.
[]Residential Water Supply shared
❑IndustnaUCommerctal PP Y(shared)
.5,'1'$".GROTfTca.•• zw.v.,.- u� _�- ..a .Pa.nr...
❑Irri ation ❑Wells>100,000 GPD FROM TO MATE EMPLACEMEY METHOD&AMOUNT
Non-Water Supply Well: � it. ft. bm*h V I
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
,r,•5i'9%�,4NA/G `•--�F,T,PA`�"K tt.a livable +�?�+. ,a : Sr ,�Y-:+rs.:r
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 10i13RTtivIlY 1 atiacL?ad$ffiouaVW et'sllfneeessF"
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,solvrock type, siz4 etc.)
(5, ft. % SO I
4.Date Well(s)Completed: 3- HIS�z S Well ID# ft' 0 ft' h
5a.Well Local�on: (.�rA/� �o ft.
V'V i AS lbw !t m—5 ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. CA
_''` 9 M
eraI dlt ft. ft APR Z 5 20 3
Physical Address,City,and Zip 1
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on. .MC r'nnii
County 1 Parcel Identification No.(PIN) • _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ceon:
N W
6.Is(are)the well(s): t�Permanent or emporary IBS .itgning
ied ell Con c Date
thisform,Ihereby cert�that the well(s)wa ere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o CAC 02C•0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If This Is a repair,fill out known well construction information an 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 thisform. 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
constmctio ,only 1 GW-1 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: b (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If dVerent(example-3@200'and 2@1001
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
If water•level is above casing,use"+"
if Borehole diameter: y (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11. Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a i r 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
I Dl Permit Program,1611 MSC,Raleigh,.NC 27699-1611
13a.Yield(gpm) Method of test: 6 W
13b.Disinfection type: Amount: 2
Fonn GW-1 North Carolina Department ofEnvironrnental Quality-Division of Water Resources Revised 6-6-2018