GW1--03148_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only_
1.Well Contractor Information:
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14.WATER ZONES
Well ConuactorName 1- _ rtwM TO DFSCt WHON
3�Z- rn �� � n• (off n- �'v►•lu-
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NC Well ConnactorCertificationNumber
is.OUTER CASING for multi ensed wells OR LIlVIIt Tipble
apt S FROM TO DLUME R TBICK1�99 MATERIAL
tit W W ft: I ft. I in. I -
CompanyName -
o�q 16.IlV14ERCASINGORTt1BING eotbermaldosed-Ioo
2 Well Construction Permit#: '"�3 n 1 3 FROM To DL4N fm Tlut�ss MATEMAL
List all applicable well consmrchon permits(e.UIC,County.State,Varlance,eta) j­( n• j'� n• c�� I in. LLD
3-Well Use(check well use): �2 G ft. Sa
Water Supply Well: 17.SCREEN
nIL
TO DIAMETER' SLOTSEEE M310ENM❑Agricultural ❑MtunicipallPublic Z ft t` m. 6U❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL h-
❑1ndustrial/Commeteial .BlCesidential Water Supply(shared)
j 1&GROUT
131r1 'on ❑Wells>100,000GPD FROM TO EM11ACEMENTMET1101)&AMOUNT
Non-Water Supply Well:. p fL Z( %
OMonitoring ❑Recovery M M
Injection Well:
iti iti �
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ds lic6ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EU11.ACKMENTMEIHOD
❑Aquifer Test ❑StormwaterD coinage n• G4 fL Y- �� l
❑Experimental Technology ❑Subsidence Control R. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if nexesm
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCREMOx color,hardness,sotvmek sans eta
' r v fL Z_ fL
4-Date Wells)Completed: 'Z`�'�� Well HW Z M Z� �Q z
Sa.Well Locatiol�n• ft- &2 fL 2f�� tsy:+-tom•- �G3��) � t�
OL
FacilitylOwnerName FaciilityID#(ifaWlieable) ft. It ram'•.P 2 "'' *�
PhysiedlAddress,.City.and p, 8 h9l�Y 't1
vT\,,W�"t._ t1L3dv l 21 R>�MARIfS .
County Parcel Identification No.M ltli Pe lira
. .. .. `ti a •'ciLta
5b.Latitude and longitude in degtees/minutes/seconds or decimal degrees:
kwell field,one lat6ong is su0icient) 22.Certification:
b ` ft
v 1 !t
6.Is(are)the we0(s): C�Permnneat or ❑Temporary Sigoahue of CatiSed well Contractor Date
Bysigning thisform,l hereby ce&fythat the weQ(s)was(were)construded ur arrardancewdth
7.Is this a repair to an existing well: ❑Yes or C�JiVO 15A NCAC 02C.0100 or 15A NCAC:02C.0200 WeII bmutrudian Mondmdr and that o copy
Ifthis is a repair,fill out Jbzmm well construction information and esplala the nature ofthe ofthis record has been provided to the well owner.
repair under421 remarkssaWonoron the backofthisform.
23.Site diagram or additional well details:
&For GeoprobeMPT 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'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �Y (ft.)
For multiple wells list all depths ifdi,Qm=1(example-3@200'hard 2()a 100) Subunit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing' (R•) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level d above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b:For Injection Wells:Co to D._ Under
il.Borehole diameter_ (ia.) PY WR, _,ground Injection Control(IUC) .
Program,1636 MSC,Raleigh,NC 27699-1636 -
12.Well construction method: l
(i a.auger,rotary,cable,direct pnsb•etc-) 24c for Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county health department of the county where installed-.
FOR WATER SUPPLY WELLS ONLY:.
24d.For Water Wells nroduclue over.100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh, C 27 9-1611
13a.Yield(gpm) J Method of test: W
13b.Disinfection type: 1 b'l i--(f Amount:
Form GW-1 North Carolina Department of Eavaonmental Quality-Division of waterRessoitrces Revised 64-2018