GW1--04388_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: , '
1.Well Contractor Information:
0-0. 01A 16d,ti4 K'ATER. t)1VES r ". ..... .,Well Contractor Name FROM TO DESCRIPTION
• ft. m ft. en
2�1� ft. �/ . ft. ~ ��1.1 .
NC Well Contractor Certification Ntuber
f /lnl /tI pvtAtil rOb1t7L Vil 11 5 co FROM ft TO tt DIAMETER to THICKNESS MATERIAL
Company Name •`to
�J 18?0 lERC U11,0R4,11BING('euthermattt ed4titi , _ ` . :':
2.Well Construction Permit#: Ct - 0 0 0(9 CO) 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.
NII:WWater Supply Well: FROM REE TO DIAMETER2, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.'
❑Geothermal(Heating/Cooling Supply) Clitesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Iaigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT` ETHOD&AMOUNT
Non-Water Supply Well: 'b ft. n 0 ft. ' $ l �c OWr1
❑Monitoring ❑Recovery ft. f-�/ ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19.SAND/GRAVED-PACIC'(if apphcable) < ._.. .
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING"1(lG{atiach additilei al sheets_-if-necessary)' , . ...;. _-
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fc. � ft. Lt /�,
4.Date Well(s)Completed: _ 5'� Well ID# ft. �� ft. ire
� a(TIC
5a.Well Location: it. 1 tt.
l ft. ft. 7,<% __�rtl. 1 Z.:n
Facility/Owner Name Facility ID#(if applicable) ft. ft
[ 0 20 01 efitirk (rk i Sffil k fit ft. ft. JUL 0 7 2023
Physical Address,City,and Zip l ` r ft ft.htf it t Pr 7 i i��
a ` 6'ro0 U ' 19 .Z3.:R1-MARICS :_. _ ..,.._ and : ,i V i ,,,..�: ,._
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:N W r ; ` 6 - 5 -2-
,
6.Is(are)the well(s): ❑Permanent or CTemporary Signature of ertified 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 Elio 15A NCAC 02C.0100 or 1SA 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: 1 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: �v 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@200'and 2@100')
10.Static water level below of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I10.Statir c el is above casing,use top Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter (in.) 24b.For Injection Wells: Copy!to DWR,Underground Injection Control(IUC)
4-6,1
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 'mil,1 P ! ° 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
��) Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) rr__ Method of test: • ®W
13b.Disinfection type: i)+-VI Amount: [ 12— 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018