GW1--03760_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
547V 5041 14:WflIER�(SLVLS .._;
Well Contractor Name FROM TO DESCRIPTION -
,��`,� ft. 3b ft. yA
ft. ft
NC Wdll Contractor Certification Xb QLJ,VWf °l15.`.UU:TER--_C-ACY_V1 p' J FROM TO DIAMETER THICKNESS MATERIALCompany Name V �( (] �N IDCt ft `„ in.
2.Well Construction Permit#:
U� r� 1[ ,1.��ININER`.CASTLYG OItt'PUSIIJGW;
- J ;J FROM I TO I DIAMETER THICItNES5 I MATERIAL
List all applicable well construction permits(t.e.UIC,Counq,,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): R. ft. in.
Water Supply Well:
FROM TO I DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural 13 unicipal/Public ft. ft. in_
❑Geothermal(Heating/Cooling Supply) Wresidential Water Supply(single) ft. ft,
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Itri ation ❑Wells>100,000 GPD FROM TO. MATERIALc.. EMPLACEMENT•METHOD&AMOUNT
�
Non-Water Supply Well: ft. 10 fr. till G/� ,
[]Monitoring ❑Recovery ft. ft.
Injection Well:
it. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salini Barrier i9 BAiVD%GRTO EL.PA- MATERIAL
q g ry tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 2t1'tDRILL?NGIOG aftauli:ndd,'tl'o'nulsheefsif-recess t.; ;i ,
❑Geothermal(Heating/Cooling Return) (explain under#21 Remarks) FROM TO DESCRIPTI color,hardness,soft/rocke, rain size,etc.)
P ,it ft f IL
1:01111itutud. 4 r ow", v= Weil i&# "• "g°p 'U
5a.Well Location^ ft• (s ft,
4-3
Facility/Owner Name Facility ID#(if applicable) fi ft.
J,, y r}VNt/ dis ,r r pifmtelf tN (, 023
Physical Address,fity,and Zip ft. ft. t 16"A
_1J c�y1n-5-roh rZ1 REMARKS r;s° r i7 r
County Parcel Identification No.(PIN) C"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.C ' cation
2-3
6.Is(are)the well(s):� ermanent or ❑Temporary S 0fi.VdC..ta. r Date
JJ �i y signing finis form,1-hereby certjy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 02C.0100 or 15A I IC 02C.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.
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
cnngtrn&;nn,nr!-I r:til,i :e«PpAvA TneV: _}_'M.rAT 'TTT?• farlri!CaA(KP!l:«po-,vrl,pnw-) y_„ zt_;._ _
- ._-_. ..-___................................__.....
°ariiied:_� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r (ft.)
For multiple wells list all depths if dierent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: T (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
I Program, 1636 MSC,Raleigh,NC 27699-1636
iyc.ror water Suppiy ana Upen-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) '3d Method of test: b Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: 1 16,
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