GW1--04572_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only:
1.Well Contrac or Information:
'' ) C.�4410._. la:WATER-ZONES ,,• .. .-.
Well Co FROM TO DESCRIPTIONntractor Name
C 2-3-.fit- fL
NC Well Contractor Certification Number' -is.OUTER CASINGtforniulti-caaed Wells)ORLINER(lf en"Iieah[e) '`` ,',
�- FROM TO DIAMETER THICKNESS MATERIAL qn (.:r t e c .��443f/Z1/ 6 , ft. , in ,. .,
'Company Name :,.`; ,,,o
• -_7 )(�` 16.INNER ASING OR>TUBLoeG(geo#Iivrmal chased-loop).H:
2.Well Construction Permit 4: Ptiti S A9 -/00d1 ! !r0 FROM To DIMAitit" THCKNESS MATERIAL "
List all applicable well construction permits(,e.VIC:County,State,Vtnlanc. etc.)
3,Well Use(check well use): ft. to M. ,
Witter Su I Well: I7.SCREEN . '�, e -
PP y FROM TO DIAMETER SLOT rIZE THICKNESS MATERIAL -
DAgricultural °Municipal/Public L i5 H. 9 't, Z in. leCizo f P J
°Geothermal(Heating/Cooling Supply) kesidential Water;Supply(single) '" ' ft. ':ft. in
Olndustrial/Commetcial, °Residential Water Supply(shared)
I73rrieation—— _.--_. . _. ___OWells>100,000GPD---_ _.___ FROM TO MATERIAL EMPLACEMENT. 110DSAN0 NT '
Non-Water Supply Well: 3tt IL 0
°Monitoring ,DRecovery so ft. 3 ft.(�'/-�l'z(1 G "6 . .
Injection Well: ft. ft. � `
oAquifer Recharge UGroundwater<.Remedietion
':I9.SAND/GRAVEL PACK(If applicable) . " ' - -
°Aquifer Storage and Recovery -OSalinity Barrier. FROM TO' MATERIAL EMPLACEMIENFMETUOD ' . ,
°Aquifer Test .DStormwater Draina$e /30 R• 1,0 4' �1'I f fie t xr'ce,� -
CoExperimental Technology °Subsidence Control ft. It !�'
DGeothemtal(Closed Loop) °Tracer '" _ 20 DRILLIiIG L'OG(attach additional sheets if necessary)'.-!... -' • .r
FROM TO.. .DESCRIPTION(color,hardness,soittroctc tyre,grain alre,etc.)'
(C ng/Cooling Return) °Oilier(explain under#21"Remarks) ft, ft: •
4 Date Well(s)Completed: Za /- well ID# ft: ft. r^-. 1,
Sa.Well Location: ,
an t, :. 41)1e ye106 ' 1 1 % 2023
Fact4tylOsvner Name Faeduy ID#(ifapplicabla)
ft. ft.
4 ,i '�
sk
Physical Address,City, .Zip , ft. ft.
/"i-i- ',%)le a :Ii REMARKS
Coady Parcel Identification No.(PIN) -
Sb,Latitude and longitude in.degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is fflieient) d i �! 22.Certifica o
3c3. 7 _N 77 12
_ /7/5
6.Is(are)the well(s): Permanent or '°Temporary
O tyfe of ittect nuuctor Dat
, ' going this.fops',I herebycent&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: -DYes" or 10 ,I NCAC 02C:0100 or ISA NCAC 02C..0200 it'd!Constructian.Standards and that a copy
if this is a repair,fill ont&noiLn well co srruction h fonnatlon and explain the nature oflhe ofth is record has been provided to the nel/:owner.
repair under it21 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the hackof this page-to provide additional well construction info.
construction,only i G1V-1 is needed. Indicate TOTAL NUMBER of wells
-(add'See Over'.in Remarks Box).You may also attach additional pages if necessary. ,
drilled: // -2.1.,SUBMITFAL-INSTRUCTIONS
9.Total well depth below land surface: 1 l Q O (n•) Submit this•GW=1 within 30 days of well cmirpletion per the following:
For malriple wells list all depths if different(example-.3(4300'and 2g100) ..
10.Static water level below top of casing:. ( 24a. For All Wells: Original form to Division of Water Resources (DWR),
If uwter level is above casing,use"+"
i )- Infartnation Processing Unit,1617 MSC,Raleigh,NC 27699-I617
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11.Borehole diameter; "1J 5`'Y (in.) 2tb•For Infection Wells:Copy to DWR,Underground Injection-Control(IUC)
,( Y Program,1636 MSC,Raleigh,NC 27699-1636
12.Weil construction method: 1e..L.0- t`Li 24c.For Wafer 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). 0 Method of test: i4 IVL Pernnt Program,161 LMSC,Raleig}t,,NC27699-1611
13b:'Disinfection type: )4 4- H Amount: ( 0.7 i . -
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 .,