GW1--03772_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
►YA'IER'ZC1Nt , v
Well Contractor Name
/11 / FROM TO DESCRIPTION
ft. ov IL
fc ft.
NC Well Contractor Certification Number I 1S.'.OUIERCASING`foririulh cased?wells;bR'LINER`if a 'licable
CA S �� } FROM TO DIAMETER THICKNESS MATERIAL
Company Name. 1r ft. ® ft. in.. 1151
15 u i M
i :26 INNER CAS G.OR Ti3SING: `eot5ermsl'closedi6o' i
2.Well Construction Permit#:C L1 1 FROM TO I DIAMETER I TIucKNEss i mATERIAL
List all applicable well construction permits(i.e.UIC,Como,,State, Variance,etc.) ft. ft. I in,
3.Well Use(check well use): ft. is in.
Water Supply Well: 17:;SCREEN, :. Y• .. :. „4 .. ....:;
FROM TO I DIAMETER SLOT SIZE TRICKINESS I MATERIAL
❑Agricultural Drunicipal/Public it. tt. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) . ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:_OROBT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT�lETROD&AMOUNT
Non-Water Supply Well: ft. �O ft. ;
❑Monitoring ❑Recovery ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.�;1wsaNnYt=RA'tTEL`PACIf:lr.a. licabre ;..
❑A uifer Storage and Recovery ❑Salim Barrier E -'OD q g ry ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -.20:i") -I 'I,1­L. attach`'addttiunafsheef§afi ecedsa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM To DESCRIFTIo (color,hardness soillrock type,grain size eta)
ft. � ft.
Y.-ALG Yr C11k3J 1.U111I11CLVU: 1 .0 ""/ W ell LJJff N "' ' -vo --a n i•1'le Y o
5a.Well Location: ft. ft. V I Y/^V
Facility/Owner Name n - �acility ID#(if applicable) ft. ft. "-
;.. JUti G 2423
Physical Adds s,City,and-lip ft. ft.
County Parcel Identification No.(PN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.C ti cation:
N W o
f"5^Z3
6.Is(are)the well(s): JPermanent or ❑Temporary sign fCe ifi ell ontra r Date
L :g;:;;g i6,a jwvn,i ilel euy ceriijy inai the weiiis)was(were)cortsp-ucted m accoraance with
7.Is this a repair to an existing well: ❑Yes or A0 1 -4 NCAC 02C.0100 or 15A NCAC 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:
S.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
,.nnef.-,.-f:.„ n.,1..1 MILI h r., larlrl,Sen('hrnrl it A Pnv. Nrnli . ..1e.,�,__;.t --tr,;-
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft,)'
For multiple wells list all depths if'd fferent(example-3Q2000'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),
Information Processing Unit 1617 MSC Raleigh,NC 27699-1617
If water level is above casing,use' g g
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
LL Program, 1636 MSC,Raleigh,NC 27699-1636
.e - -rotary,cable, re - — - LY1.rur rimer 6 i and G en-Loo Geothermai 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
9Q�13a.Yield Win) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
1 �"'
13b.Disinfection type: .1✓1 Amount: