GW1--04381_Well Construction - GW1_20230707

. WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
'�t7 U1 f ao ISi •14 WATER:ZWIES s r<:
Well Contractor Name FROM TO DESCRIPTION
li I & ft. . 20 ft. a m
ft ft (�
NC Wellel/n�ll� Contractor Certification Number /� .' 5.OII,T);RCASING:(formnlh-casediwells)OR'LINQERF,A(ifap hcable)r
\/1.' Po � .�IJ poll
V"tFR 5 ft. TO r DI ETER in. HIC i) Sl MATERIAL 41 � , .
174
Company NameY � OF
�1 p` ✓� ,16.ANNEFKA ING OR.TUBIN teotheeirOCIosed long _,
2.Well Construction Permit#: (I(i ll l !L3 1 t"f —i U /i J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale, Variance,etc.) . ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .WSCREEN °`; '
PP y FROM TO DIAMETER SLOT SIZE THICKNESS i MATERIAL
❑Agricultural ❑ unrcrpal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Ig GROUT , ,.<
❑Irrigation ❑Wells>100,000 GPD FROM TO MATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n ft. g 4, ft. b v�(�,. �y,, ii+
❑Monitoring ❑Recovery F� ft. A 'l/ ft. `v �/ ��I u
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 AiVD/GRAVELPACK`(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20.3)RILLING'LOG`(attach additional sheets if necessary)=' ,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/CoolingP Return)*� ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 1D''d'46— '3 Well ID# ft. ft.ft. ft.
Sa.WellLocation: ,,'"--1) —!' r1..-
o\Ah Kairhllr�1
Facilittyy/Owner Name
q / y� Facility IDD#(if applicable) ft. ft. 11�1 0 `Lt-in
VCs �&c. et�1 f '2 ' 11.r\Vf r f�i5q ft: • ft. 1V. ^-
f ft. ft. ln;�; r s �`=
Physicaly�( Address,City,and Zip 1 Q q( r r1 ^ C o J
k QiiL1L l 0 b�V d�� Z1.REMAR[CS
County Parcel Identification No.(P )
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer• ation:
4 )TJ3.3
6.Is(are)the well(s): 4ermanent or ❑Temporary Signal certified W_el`l Contr or Date
By s g g 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 No 15 CAC 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.
repair under#21 remarks section orlon 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: l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 V (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 00'and 1@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1."‘a (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'•+"
11.Borehole diameter: (2 (in.) 24b.For Injection Wells: Copy Ito DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4.11( 0 4-Qy- 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
f,) Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) t Method of test: I '
13b.Disinfection type: d Amount: 112 t/b '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018