GW1--03682_Well Construction - GW1_20230530

• i
WELL CONSTRUCTION RECO ,(GW-1) • For Internal Use Only: • •.
' 1.Well Con o ormation:
ra •
• `
eA 14.WATERZONBS
Well CoatraetorN�ina FROM' TO DESCRIPTION
•
ft it.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(trap liable)
11
✓ /1 FROM TO DIAMETER TRIMNESS MATERIAL
I ,I • ft. ' . ft in.
CompanyName 16.INNER CASING OR TIMING(geothermal closed-loop)
2.Well Construction Permit#: PR S is 022 D 3 a7 FROM To DIAMETER THICKNESS MATERIAL
•
List all applicable well construction penmits(Le.WC,County,State,Variance.ere) • -+ I ft. P ft S 7AI in.
1C.►'l.. Y.v ft.3.Well Use(check well.use): 'n
Water Supply Well: •
,.7.SCREEN.
FROM TO . DIAMETER SLOT SIZE TRICIOYESS MATERIAL •
• ❑Agricultural 'OMtnricipal/Public • ft _ ft " •- in.
•
[Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft in•'
Olndustrial/Commercial ❑Residential'Water Supply(shared) Is.GROUT
OIrrigatioli . OWells>100,000 GPD •FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 0 ft L3 ft 111--ta 1 {,'
• OMonitoring . . ❑Recovery it ft. fp
Injection Well: Or -r NA p1.... I,-A
ft ft
❑Aquifer Recharge OGroundwaterRemediation 19.SAND/GRAVELPACKCdapplicable)
•
❑Aquifer Storage and Recovery . OSalinity Barrier '• ' ' FROM • TO MATERIAL ' EMPIACEMENTMETHOD
OAquiferTest ❑StormwaterDrainage - ft. , , ft
•
❑Experimental Technology ❑Subsidence Control ' ft ft •
❑Cieothennal(Closed Loop) ' ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardness,saVnek type,grain Az,ate)
• ft ft
4.Date Welits)Completed: .5-'2`f-4 3 Well ID# ft. 'ft. . •
5a.Well Location: ft • ft - u-. -> 7--.' .
._.1 Cl/YY .l- —To ea - ft ft tl ...
• Facility/OwnorName Facility ID#(�p'cable) ft. MAY 0 2023
D6bb� -- ('r 1n ' ' . •'ft ft -
• Physical Address,City,and Zip ft ' ft. 1,;......;,-.2:-1 r p. :�!'f
Sf h)-et.' AA1 1 1 c A , U .. ("—) 21.REMARKS!
County Parcel Identification No.(PIN) •
Sb.Latitude and longitude in degrees/drinutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) '22.Certifies. n:
•
�, N/ i�1 � ' 6r - cr .2-7 .. w - 40 '54.144:47( ,.... -z>.--....z -a
.6 Is(are)the well(s): permanent or ❑Temporary el'$ 1 Signature •'• Contractor . Da, •
r� �� Bysfgning this,•im,
444I1kr*certify that the wel(r war(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANo ISANCAC 02C:0I00 or 73B NCAC 02C.0200 Well Construction Standards and that a copy
If this isa repair,fill out brown well construction information and captain the nature erne of Mir record ha:been provided to therrcII owner.
•repair rider.#2l 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
24.SUBMTITAL INSTRUCTIONS •
9.Total well depth below land surface: (ft)
Formulrlple wells list all depths ifdperenf(esantpk-3Q200'and 2 plea) IL
Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing: • 2-0 • fl: 24a. For All Wells: Original form to Division of Water Resources (DWR), '
Ifwater level is above cash&;use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
ry
11.Borehole diameter: t2/O . • .(m) 24b.For Injection Wells:Copy to DWR,Underground injection Control(IUC)
Program, MSC,Raleigh,NC 27699-1636
(ie12.Well construction cable, method: 1 0 a k 1_ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
•
(r a auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
•
• FOR WATER SUPPLY WELLS ONLY: •
//��
r, 24d.For Water Wells producing over 100,000 GPD:Copy to MR,CCPCUA
- '13a.Yield(gpm) r 1)V Method of test: a PermrtProlparn,1611 MSC,Raleigh,NC 27699-1611
Is
13b.Disinfection type: r 7 D Amount: .I 6
I • .