GW1-2023-02969_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (Q W-1) For Intemal•Use Only:
1.Well Contractor
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I�formatijon::
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Well Contractor Name FROM TO DESCRIPTION „
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NC.Well Contractor Certification Number .. t ,� „,n•r...T rrl%. w s., a_v.Y,nb Y.n.e .rre�ot:.�.•^,r<
�j FROM TO DIAtiIETER THICIGYE35 MATERIAL
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Company Name
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2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permiu 6.e,'UlC Como,,State,Kai ee;etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water..Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
flAurkrildiral I'lpMnnicinal/Aihlic tr. ft. in,. :'
❑Geothermal(Heating/Cooling Supply) t�Resideutial Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri atlon ❑Wells>100,000 GPD FROM To MA07
EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: ft. N tt.
❑Monitoring ❑Recovery ft, ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
(�Armifrr Ctnraar.aril RrrnvPry I lCalinity RarriPr fJ'S 11/GK;
a nu Ttv 4T ATR.UTAT. rxmT.ArFxm,,vTmv.T1 iTTln
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer s
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color buftess,sal0roek gpe,grata dm eta
4.Date Well(s)Completed: �� Well ID# 1t. to
5a.Well Location: h• �,��
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Fac17iry/OwnerNeme 1161ity1D#(if applicable) Q ft. ft. r—IL
yq-n(,.Fy ecl U17A, V` 6 ft ft.
P ical Address,City,and Zip ' ft
County Parrett Identification No,(PIN)
5b.Latitude and loneftude,in deer ees/minutes/seconds or decimal degrees:
(ifwellfield,one latilong is sufficient)
2 e fieatlgn:
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6,Is(are)the well(s): permanent or ❑Temporary of Certified Well Co or Data
lBy!sIgning this form,I hereby ert6 that the well(s)was(were)constructed in accordance Wth
7.Is this a repair to an existing well: ❑Yes or 4o 15ANCAC 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 and esplafn the nature of the of this record has been provided to the well owner,
repair under#21 remarks section or on the back ofthisform.
23.Site diagram or additional well details:
Von.ran ncn it,n 1.anL of ihio noon In ntrnrirt.oAAi}innol mntl nnnetntrtinn 1nfD
b.1•Uf ltCUilraluC/3/F1 Ur�.1WCL LUUI1 trCuluci LULL rT C1i5 L'bviug wo balliG
construction,only Y GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sea Over'in Remarks Box).You may also attach additional pages ifuecessary,
drilled:
pp��, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ V (ft.)
For multiple wells list all depths if different(example-3@200'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use +u Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) ( 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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12.Well construction method: Y r no 4A 24 c.'For Wate r Su I and en-Loo Geothermal Return Wells:Copy to-the(i.e.auger,rotary,cable,direct push,etc.) dpmy envimi�thClepartment of the county where instOW
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: ® W
13b.Disinfection type: Amount: t
Form GW-I Nor fi Carolina Department ofEnvironmentalQuality-Division of Water Resources Revised 6=6-20I8