GW1--03164_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
tl a 1 e, i
S 0r4_VuIt? 6s s .'.
FROM TO DESCRIPTION
Well Contractor Name
ft. � ft. 1 n m
�] ft r v ft S ffi
NC Well Contractor Certification Number
?7i15.,0i)?l F311 Cz$SII'1Cr Aor multt,czi9e > Its t)R UZNER iCa'"licalilc
FROM TO DMAI ETER THICKNESS I MATERIAL
in.
_ lit 119
.Company Name r� k;'16.11?f1+I:I`sR C}A. �iI;:FSR�•'1;[kB11�C#,'''e4therma��cluse�l+6' ,`��'u. }nh°�.�.r!.-.=���r)>
2.Well Construction Permit#: W FROM I TO DIAMETER THICIGITESS MATERIAL
List all applicable well construction permits r.e.UIC,Counq,State,Variance,etc.) In.
3.Well Use(check well use): f, ft. in.
Water Supply Well:
FROM TO DI414ETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft., ft. in.
❑ • RGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
ash
❑Irri ation 0Wells>100,000GPD FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT .
Non-Water Supply ell- it. ® ft. key gt 1 9 ritu�
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier. FROM. TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL h•
[]Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer >20I3Jt1UAaa%
Lb,Gfattacir addrttonal si►eetsiEneoess "a :nz�" -s?
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM To DESCRIPTION(calbr,hardness,soil/rock type,grain size etc
% ft. g
4.Date Well(s)Completed: Well ID# a, n' ft. Ik j`l
5a.Well Location: ic. 0 ft. ,K
Pi i'D - ��Y ft. o �e
Facility/Owner Name Facility M#(if applicable) ft. U a 2023
s f-�z(6 --!r J
Physical Address,City,and ft. ft
Pan 01i �:,Zi,:RF'iIYIeY `.:t:h��:i,Y 5-:�:. �'.5�:�:YiF{>''a.,, �;:'i v r 5_�•....ti.4.�rir.x`-..b`: '�.�.t�.e,r-::
County Parcel Identification No.(PIN) A60-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d
(ifwell field,one lat/long is sufficient) 2 . e fi n: 2
l N W J 24'-26
6.Is(are)the well(s): QPermanent or ❑Temporary 5' rtified Vrd Con7ac Date
signing this form,1herebycethe well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CINo 15ANCACO2C.0100or1SANC.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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well consttuction�info
8.For Geo, o only
I G or Closed-Loop irate TOTAL
Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2©100D
10.Static water level below top of casing: ao (ft) 24a. For All Wells: Original form'to Division of Water Resources (DWR),
If water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11,.Borehole diameter: (in,} Pragra,,,16361..SC,_akish,,TC 27699-1536
12.Well construction method: a[r 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 w ere installed
FOR WATER SUPPLY WELLS ONLY: 1-t 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gP m) ;; Method of test' �® Permit-Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: �.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018