GW1-2023-02970_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information.-
Saw 1 @ 6o JI
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FROM TO DESCRIPTION
Well Contractor Name ft. 1*70 L
1!31 A r
NC Well Contractor^Y Certificati Nu r mbe
I 1$;."O1J#TER,CiCSIAIG for m>)lfi t ased wells bR 1IlZER if a' 4cable ix,;?,: t;?w.
h FROM CL it TO DIAMETER THICKNESS MATERIAL
.Company Name 1. O in
C�� � .�� [J'� � ,r16�TF�IIVER CASIl`I,G;67�iT.tISINQ�''eotlierma'lYclosedlao
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC.Count;State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft..
'IZY.iS,ERF3�'`L.F�.)7,=,g-c.0 :.�4...:�'1�...t:<�1;f ..1. .�.�. rl'.,rY,..Y..rS�5s5a�...s,a..,.T-:r+•�.}t,``.a..fix -�'.:`.'ro•.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. I in..
❑Geothermal(Heating/Cooling Supply)' ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Xs-'t Ro71T ...❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. �' r o
❑Morfitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation , Y
❑Aquifer Storage and Recovery ❑Salinity Bairier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage fL ft.
❑Experimental Technology El Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2D l#t7L71IL+CG3,C3GattacLa$ditohai,s]teets>ifneeess
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soll/rock a grain size eta)
t^1 , rt. it.
4.Date Well(s)Completed:�- -�� Well ID# d� /i� 1 ft. ft. a
NSa.Well Location: Ur�ll a�e, IV ft. `I, a r O CIR
I .:-.
C, u r 'i e, Cl c/1%✓1 J ft. ft. s�.,:. A V
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�, OO ,I[p1 1 �''7 0 [ 9 7
_ a VI W V` (/�J U -,f j ( Ct. ft. a to 2,
Physical Ad ess,City,and lip II ft ft +Oil�f^G RA
rv�1� ,23... .. . ... .
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.C IC on:
N W
6.Is(are)the well(s): ermanent or ❑Temporary S' ature of Certified Well C tractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lAo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out(mown 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths J'dier•ent(example-3Q200'and 2@100)
170.
24a. For All Wells: Original farm to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
4'water level is above casing use'+'
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
1 Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: G (r Y 07 4 or y 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 preiducing over 100,000 GPD: Copy to DWR,CCPCUA
/I I 13a.Yield(gpm) 0 o W Permit Program,1611 MSC,Raleigh,•NC 27699-1611
6 Method of test: y
13b.Disinfection type: Vi�l'1 Amount: 2 Is'
Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-2018