GW1--04385_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
c s ®n Po Y 14 WATER ONES °
Well Contractor Name FROM TO DESCRIPTION
ft. 1 o ft. 3d l frh
eY1.-1 IA ft. ft.
NC Well Contractor Certification umber I5:OUTER CASING(for mull cased`;wells)QR`LINER?(if ap licafile)
•1 1 r`L� rI.t Weil 1 PIA.r•`r CID, FROM TO ft. �"l ft. DIAMETER m. THICKNESS� OS Qiv I•1k�,����
r .
Company Name
G,,` 0 s��1;1 ^ , : _ KDINERCASING OR-I'_f1BING( eothermal?clased7ooji).. ..
2.Well Construction Permit#: W `T Y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft.• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: lFROME TO DIAMETER'` SLOT SIZE _ THICKNESS MATERIAL
❑Agricultural ❑�/Municipal/Public ft. ft. in.'
OGeothermal(Heating/Cooling Supply) ISTResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
I&,GROXIV:?, f
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEME- AMOUNT/METHOD&AOUNT .
Non-Water Supply Well: D ft. 2-d ft. be ITf/��1 rciv r 1 )
❑Monitoring ❑Recovery . ft. ft. i
Injection Well: ft. ft.
:Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
• ❑Experimental Technology ❑Subsidence Control ft. ft. .
❑Geothermal(Closed Loop) OTracer 10 DRILLING` 'OG(attiel additiot at lleeta f iiiiesia&MAMtWgrMakMM
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) .
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. ® ft. {�1,r� a
P^
4.Date Well(s)Completed: I ^ la Well ID# (0 ft. r 0 ft. lI aikelC5'V�Z Q Cori-1 (OP' ,
Cl ft. ft.
5a.yWell Location:
aJ O 811Avel- d 1"1 ft. ft.
Facility/Owner Namer. C -/Facili #(if applicable) ft. ft. r..-;rz-^(' �_s a T.:! ,
i�®S 5 v 11 Jo ! V r t 6 r i �1.e L -1 P f® ft. ft. 4 's ke.,a.,�+i..ea a ''I FT.:y -
Physical Address,City,and Zip I ft. ft. J I J L 0 7 2023
�. y K 21.32E1�'IA$ICS ,. „ ,. 't,., t
\Vr`fl ji v
County Parcel Identification No.(PIN) r'"; ;°1'1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C nation:
N W _ 6- 1 - 21
6.Is(are)the well(s): I3fPermanent or OTemporary Si of Cert re ell ntrac Date
y 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 fiNo 1 SA 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.
repair under#21 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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf different(example-3@200'and 2@100) '
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: v (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)V Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a I f (O�G I 0 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)
® Method of test: 6 to *) Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: k 4-t% Amount: ikzti
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018