GW1-2023-02967_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
06 I 14 WATER ZQNES
Well Contractor Name a FROM TO DESCRIPTION
ft. 'S ft. 3
ft. ft.
NC Well Contractor Certification Number
1'S.,,OU'TERCASIPIG for:m'uih-casetl`�we11s,OR=hINER','ifa ucable
�^ r�I ��� I �rA FROM TO DL4,METER THICKNESS MATERLA1
Company Name` t 11, 16.�fN1�R C2A 0 ft. ft m PVC i
o r ,
L,( 4, SIIVGRT O :2BING"'eothermaTclosed too"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriculturai ❑Municipal/Public ft. tt. in.
❑Geothermal(Heating/Cooling Supply) FiResidential Water Supply(single) tt.- ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO , MATERIAL EMPLACEMENX METHOD&AMOUNT
Non-Water Supply Well: "
❑Monitoring ❑Recovery
Injection Well:
it. Ct.
❑Aquifer Recharge ❑Groundwater Remediation
14.SA1�iA/GRAVELPACK'°eta `licatile , _, _.;> .
❑Aquifer Storage and Recovery ❑Salinity Bairier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2D..DRILLINGYOG attach'additioual`sheets-ifnecessar ;.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soiltrock type,grain size eta)
ft. ft.
4.Date Well(s)Completed: �Zr���3 Well ID# tt. ft.
ft. ft.
5a.Well Location:
V ' r�'•�`:! i V'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ii�1 nnn
ft. ft. L J
Physical Address,City,and Zip ft. ft. iflf®fR::a:t011 pf,*Z (h
-
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.Certification:
N W 9, 3 "ZID -L3
6.Is(are)the well(s)• permanent or ❑Temporary Signature of Ceilified Well Contractor Date
By signing lhis form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or 90No 15A NCAC 02C.0100 or 15A NCAC 02C.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-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: I (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: Q (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
s+"
11.Borehole diameter: w in. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a l r <r6 rV 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—Thereeinstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
l 13a.Yield(gpm) v Method of test: Permit Program,1611 MSC,Raleigh,,NC 27699-1611
I_
13b.Disinfection type: Amount: Z 7-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018