GW1-2023-02981_Well Construction - GW1_20230425

ry r,tl,i, 11,u1y b 1 XU U,110.N RECOR (GWV 1) `For Internal-Use Only:
1.Well Contractor Informatio
ON
..,t
Well ConaactorName FROM TO DESCRIIgPTION
-- a q A R. f t Cl
NC Well Contractor Certi cation Number ft.
R'
OUZ);l2:CASINls`fiir mrilt[¢ag 'OR: B if a "licabFe ;t
DLLNETER THICKNESS yj�iG
CompaayName ✓� s vy R ft. in. ,r
RZAL
Y •� h16.TNNERGASjNG'ORr 11�I. edtheriuiai'clased-1'o. n:w y�'�ry r.
2.Well Construction Permit#:_ � CJ " FROM TO DIAMETER THICKNESS MARL
List all applicable well construction permits ft.e.UIC,Coungl,State, Yarr�ce,etc.) ft. ft. In
w.
3.Well Use(check well use): ft. ft. in
FOA
r-Supply Well: 77777
icultural FROMTO DIA, TER SLOT SITHICKNESS hL4TERL4L
❑ unicipaUPublic f4thermal(Heating/Cooling Supply) 7midential Water Supply(single)ustr- I/Comtilercial tt❑Residential Water Supply(shared)
ation• d3.GR0�i3.;r;: ;s;.:... .•
❑Wells>100,000 GPD FROM To
Non-Water Supply Well: MATERLII EMPLACEMENT METHOD&AMOUNT'
❑Monitoring ❑Recove fL ft.
Injection Well: ry ft. ft.
❑Aquifer Recharge ❑Groundwater Rernediation R• ft.
❑Aquifer Storage and Recovery ❑Salinity BarrieriMnrERIAL s„''
FROM TO EMPLACEMENTMETHOD
❑Aquifer Test ❑Sto'mwater Drainage ft. tt..
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer h
20;:I3 �11.E7G:a`�•eb add'tonal slieefs'$f'rre`o ssiit�' :,..; .�
❑Geothermal(Heating(Coolin Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardness aoWrock n si etc
4.Date Wells Completed: <- `n r p
() P Well ID# ft. it.
5a.Well Location: ft. R.
�� � � !
ft. ft.
Facility/OwrName Facility ID#(if applicable) ft. ft. �^�
—'��� d�Ir u'1 c11 If 1 �t. l(�- ft. ft. e :
Phys:ca Address,City,and Zip J
ft ft APR 2 5 ZO J
L
County Parcel Identification No.(PIN) ?'%onPrac ►t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if gell field,one lavlong is sufficient)
:22 Certification:
N i ..
W
6.Is(are)the we➢(s): 23
Vermanent or []Temporary Siguatu f Certified Well Con ctor ^ -
�! orm, ertifyhat Date
e7.Is this a repair to an existing well: ❑Yes or :40 1 AtNCAC 02C.0100 or ISAcNCACt 02C.020the 0(Well Construction Standards)was(were)constructed in aand that ca copy
this is a repair,fill out known well cons brtcti0n information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or an 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
construction,only I GW 1 is needed. Indicate TOTAL'NUNMtR of wells (add'See Over'in Remarks Box),You may-also attach additional page,,if necessary.
drilled:_ F
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdifjerent(eirampie-3000'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ',7 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" InformatiAl on Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1.
11.Borehole diameter: (in,) 1 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
�^ .i- ` Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(ie.auger,rotary,cable,direct push,etc.) 24c.For Water Su 1 and O en-Loo Geothermal Return Wells:Copy to the
FOR WATER SUPPLY WELLS ONLY: county environmental health department of t&county where installed
24d.For Water Wells roducin over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) � Method of test: Perm't Program,1611 MSC,Raleig ,NC 27699-1611
13b.Disinfection type: 't Amount: (�
Forui`GW-1 North Carolina Department ofStivironmental Quality Division of Water Resources
J Q ty Revised 64 2018