GW1-2023-02983_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I a6y h Nit FROM
WATER ZQlYE5 . _ I s
FROM TO DESCRIPTION
Well Contractor Name
� a_lI A f. a61�ft.
tt. ft.
NC Well Contractor
ontractor Cert lation Number `y'�I I g^l rA^ 1I56.TONTTNfERRR G CAASIIY6 OR TJBING e`ovfhee)rs matRclosed Rtf _catte5
\Arq, ` FROM
f. TO f. DIAMETER in. THICKNESS MATERIAL
N V
Company Name o 2.Well Construction Permit#: 1 1 (l�� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counp,,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: .
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. rt. in.
[]Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. Zv ft. n }
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft b s
❑Aquifer Recharge ❑Groundwater Remediation
,19 SA1VD/GRA�?E1;YAGIC"da licab _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 1Q:.1)RILLING)LbG attach.additiotial sheets if necessa`:';
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soilfrock a rain size,etc.)
ft. ft. G`Q
4.Date Well(s)Completed: �"- Well ID# lb 110 ft. Goo ft. ad. C R.- Car-
ft. ft.
5a.Well Location:
t � ft. ft.
Facility/Owner Name Facility ID#(if pplicable) ft. ft. ;=� " L.)354 5c&7�vd n 5eruCl ft. ft 2 6
APR
2023
Physical Addr ss,City,and Zip ft. ft.
2iTR1•MARICS,:�`,... .. _.,... �a�Ct•_ f�t+'>_.,... ,,..;.: ,...:.u, .._..;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signaq�e of Certi ed W Il ontractor 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: 11Yes or [INo ISA NCAC 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 explain the nature of the of this record has been provided to the well owner.
repair under 421 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:1" �ry 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Coo (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ii('dii ferent(example-3@200'and 2@100')
10.Static water level below top of casing: (ft.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a�r 1 G 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
13a.Yield(gpm) Method of test:
U I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: 160
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018