GW1--03167_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
To,._"-)bVt �6s t, ..,.....
FROM TO DESCRIPTION
Well Contractor Name
Oft. •
0
NC Well Contractor Certification Number - -
q� s l$._OLL W'12ASII+(Is for itiiilti Dose ` ells,ORiIINIrR' a 7icabTe f ;``_
G r FROM TO DIAMETER THICKNESS MATERIAL
ft ft. Co in. t�
Company Name � e ..
;3TG:IilY1;RG45I11i .flltr 11�IG;: `etlthermaXclasedlou ;.+rE.'..°. : '..s
2.Well Construction Permit 4. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Couny,State,Parlance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
;I7'; CRI;Ir'N' J.. , r...,ny...:;?. . ....'.:.;,�'..�..:v��:`
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. . ft. in..
❑Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. fL in.
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) x&GT2i1[3T r
❑Itri ation ❑Wells>100,000 GPD FROM TO MATER1,41, I EMPLACEMENT IETHOD&AMOUNT
Non-Water Supply Well: 0 ,p ft. hfdoKft a row n,'
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
3tiNA/GRe11F•Fi'PA�ICif.' lieai"sIe t r =4
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stoimwater Drainage to ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer iZb.IIItIBLINt7G attach'adt3itionsl;s7teetsitnecerss ;- T E.� r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rockn size,etc.)
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4.Date Well(s)Completed:—c�= = Well ID#_J 1_ p ft. O ft. 0 C1
5a.Well Location: fr. it ; ..;
Fac h Name Facility 1D#(if a plic le) ft. ft. VI 5L ^3�3Sr r ���Qi�► Jr. I t11�1 0� ft. ft. :5'rn't'f:^�Gbns F�t;ft
ft. ft v�I
Phy/s'calA,ddr s(City,and Zip
l .,
i t'l(tiPLa <
County - Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification:
N W 2.5
6.Is(are)the well(s): 4ermanent or ❑Temporary Si, a of Certified well ntrac Date
13y igning this for n,1 hereby certi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11 I0 15A NCAC 02C.0100 cr 15A NCAC 02C.0200 Well Construction Standwds 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:
Ycu ma;'nse the back Of th;g page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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: l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Y (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dfferent(example-3Qa 200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Rnrehole diameter: (fn.) t .,.._�__ ,co a loo n ul.: 1., ^IC 27`nno_1535
ri�g.aiu iwv. va i. ..�.,,.
12.Well construction method: Ck l r r6f ry v 24c.For Water SupRly and O en-L I bop Geothermal Return Wells:Copy to the
(Le.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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: k—+WAmount: 71I�
t:,,*,,,r.w-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018