GW1--03147_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only-
I.well Co tetra r Informatiln-
1�,` i r "`"^'``—��•' - V �ru1� 14.WATER ZONES
WellConha=Name - FROM TO DESCRUTION
3 �;'n
NC Well Contractor Certification Number
/ 15.OUTER CASDYG formuld-casedwens ORLDVI i da Te
I c I azza"- Se"J . ,s FROM TO D1AME7ER THI(�- MATBnIAL
VV Vv n n in.
CompaayName i' '�_, i �.ij -
FF 1&HOIERCAMGORTUSING eothermaldoed-l00
2.Well Construction Permit#: p`{"f f t S mom TO DIAMETER TffiCKNES9 IHiATEniAI,
List all applicable well canstntchon permits(le.WC,Cioun A on "INZ3 4-1 R- 25-3 n i� t°' J�,L C�G} V(f
3.Well Use(check well use): r ^l i�C:^•f'^' t%O 'ZA.
6,. i o u.d.
Water Supply Well: Cy.d _ 0v 17.SCREEN
FROM TO IRQJETIM SLOT SUE THiCn1N&4S MATERIAL
❑Agricultural ❑Mmicipal)Pttblic �3 n n I( tom' tj 3 S
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(she) tr. fL in.:
❑lndustrial/Commercial Aesidential Water Supply(shared) I&GROUT
1
ClIrriRation ❑Wells>100,000GPD FROM TO AUTERUAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: (� R• ! n fd 'ep Av
OMonitoring ❑Recovery n n
Injection Well:
n n
❑Aquiferltecharge ❑GroundwaterRemediation
19.SANDIGRAVEL PACK*K d applicabie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MAPMEEMPiACEMELNTMETHOD
❑Aquifer Test ❑Stomtwater Drainage 2-% n G d
oExperimental Technology,_ ❑Subsidence Control n n -
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if umessa
soiVroek sin,eta
❑Geothermal(Heating/Cooling Retnm) ❑other(explain under#21 Remarks) FROM TO DESCRIPTIONealor,hardness,
4.Date Well(s)Completed- T"Zs- Well m n- n
5a-Well Location:
n ,
FacilityfOwwnnerName���" / Facility1D# fapplirable) h it ��]
�A`J ,(�T t *r�11� "(.t 4)e-5 � IL n
Physical Address,City,and Zip ��'(� n n
2L REMARKS
County Parcel Identification No.M
5b.Latitude and longitude in degmes/minutes/seconds or decimal degrees: 7 ^�
(if well field,one lat/long is sufficient) 22. rtiSeatron: 4L `-
t'�'4 N 7�/ ��� � �P W 1 � �,� j , �Z 3
ii
6.Is(are)the well(s):4BPermirnent or ❑Temporary Signature ofChfficd W Well Contractor I, i
Bysignbrg thisform,I hereby certifytW thewell(s)was(were)constructed m accordance with
7.Is this a repair to an existing well: ❑Yes or ONB--�- 15A NCAC 02C.0100 or 15ANCAC 02C.0100 Well Construction Momdards and that a copy
If this is a repair•fill out lmown well construction information and explain the nature of the ofthis record has beenprovided to the well owner.
repair under R21 remarks section or on the back of this form
- - - - -- ---- --- --- ----- -Z3.-Site diagram or additional well details: - -
&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.SUBMPITAL INSTRUCTIONS
9.Total well depth below land surface: ( ) Submit this GW-1 within 30 days, well completion per the following:
For multiple wells list all depths ifdlfferent(example-3Q200'and 2@100)
-0-3 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Icvel below top of casing:
Ifwater level is above casing,use"+ Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. (Ip) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /
(Le anger•rotary,cable,direct posb,etc) 24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produelpover 100.000 GPD:Cop
y to DWR,CCPCUA
138.Yield(gpm) Method of test: ;�N!a9
Permit gram,1611 MSC,Raleigh,i NC 27699-1611
�13L Disinfection type: LAM-' p"l-Z Amount:
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of WaterResources Revised 64-2018