GW1--03717_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informs'on:
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Well Contractor Name FROM TO DESCRIPTION
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NC Well Contractor CllertificationNumb �^r 1S OUTER CASING Cor;mu]ta=�ased fells"OR`LINER ifs" Ilcati]e
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at r ap fi FROM TO DIAMETER THICKNESS MA EWAL
cC WM ft. 1 fL in.
Company Namef
��`�J� �� Z6.:IFIPIER,"GtSIN .OR�TUSIPI 'eothermals'losed=loo� :� s.,~,„' ;:,
2..Well Construction Permit#: �,I �J q "' FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i,e.UIC,Count};State,Parlance,etc.) ft. ft. In.
3.Well Use(check well use): ft. % in.
Water Supply Well: 17:SCREELv ; „ ,
FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL s
❑Agricultural ❑ nicipal/Public g tt. in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Cormnercial ❑Residential Water Supply(shared) 18ia ROUT =-
❑Itri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT .. THOD&AMOUNT
Non-Water Supply Well: ft. A ft. ,r
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. R.
❑Aquifer Recharge []Groundwater Remediation
❑A uifer Storage and Recovery ❑Salim Barrier 19:SAINATGRA�EL:PACK`MA `RML . ;. x. . " O
q g � Salinity FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control fit. fit.
❑Geothermal(Closed Loop) ❑Tracer 2O:DRILLIPiGL"OO:aftacti addiiionat slieefstt necessar.'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solUrack a ratn size eta)
l ft. 0 ft i
4.Date Well(s)Completed: �^ /� Well ID# too.
fL 150 SL
5a.Well Location: Q iL R• Mil
ft. ft _
Facility/Owner are f applicable) n• ft
4
Physic 1 Address,City,and Zip ft.
J2 REiVIARICS`
County Parcel Identification-No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.•Certification:
N W /�O, �Q, -
6.Is(are)the well(s): 5/permanent or OTemporary Signafe of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Ao 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out]mown well construction information and explain the nature of the ofthis retard has been provided to the well owner:
repair under 421 remarks section or on the back of this fornr.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 yy� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths fJ'd�er•ent(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ,a-& (fti) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifrvater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a / 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 where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test: 10 W Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018