GW1--04911_Well Construction - GW1_20230728

WELL CONSTRUCTION RECO (GW-1) For Internal Use Only. i . •
1.Well Conhacto ormatio
. y I ,
•la.WATER ZONES
Well Contractor Name FROM TO DESCRIFITON
53 S • //0 ft• �a ft .
NC Well Contractor Certification a
PROM ft ft.
� �J ER CASIlVG(for multimulti-cased wells)OR LINER(if ap Gea61e)
77A ' 'na-t,'. FROM TO I DIAMETER I THICKNESS MATERIAL
CompanName ft. I ft in
_ ) 16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#: R 7 I/�/ FROM TO DER THICKNESS MATERIAL
List all applicable well construction permits r a UIC;Curm ,State.Variance.ere) "4 ft v ft 15�i! in.
n �/
in-
3.WelI Use(check well use): •
�n f PY� •
Water Supply Well: • d7.SCREEN
❑Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL❑Municipa]/Public ft ft.
❑Geothermal(Reatinl//Cooling Supply) Residential Water Supply(single) - -
❑IDduslriai/Commercial ft •
in'
❑Residential•Water Supply(shared) Is.GROUT •
❑Irrigation ❑Wells>100,000 GPD FROM TO 1APTERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 103 `ft Nee. ,�^ y
• ❑Monitoring • ❑Recovery R ft Ail I r'CA.
• Injection Well: f
❑Aquifer Recharge ❑Groundwater Remediation ft ft.
❑Aquifer Storage and Recovery • pSalinityBaaier I9.SAND/GRAVEL PACK(fapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ' ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
• ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) PROM TO • DESCRIPTION(color.6anaaess sod/roek trpe Brain sas eta)
ft
•
•
4.Date Well®Completed: 7.'13'23 Well ID# ft •ft
5a.Well Location: ' e l/,, ft 6�
l)t!�'t�'! r l-.CJs/ S 6 kvt) ft ft. i� ' 1.
• Faciltty/Owner Name r
�p pp � � T Facility1I,D#r(ifaappica1ble) ft ft k--�{ '�,
C.6 • �.-K.JL kA, ! f�s v- UV a..�,t.l,V - ft A"'_ 1• � $d
Physical Address,City,and Zip if, ft. 2 - 2023
n n
LO
County J�x'L 21.
ParcalIdeatifieatioallo. I2EMARKS.! �',�.�n I
IP1EC
(PIN) atVA,)-'sl
fZlsx` W21,,tiu
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:
51,,' 1L' .AK 'N fib ' - 53' Ib ' ' W
6.Is(are)the well(s): ❑0rmanent or ❑Tenp o rarypra ti#14r1-1 Z3
/b /U I Signature , Cestifi :Well Contractor Date Date
By
7.Is this a repair to an existing well: ❑Yes or ,to ISANC4C 02Cing this:0I00 or I ANcAr 02C.0200 hat the well(s)was
Co erucconstructed
ion S amr�and accordance
a with
copy
If this is arepair,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 fonts
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: 2 7-0 • (ft) •
For multiple wells list all depths ifdperent(example-3Q200'and2©Ioo) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of,casing. Cp Q (ft) 24a._For All Wells: Original form to Division of Water Resources (DWR),•
Ifwater level is above ea+ing:use Information Processing Unit,1617 MSC,'Raleigh,NC 27699-1617 •
11.Borehole diameter. LP u ,(m) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: 'R 04 a- (-.11.
lie auger,rotary,able,diem:push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
•
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) 2-0' Method of test: Pest Program,1611 MSC,Raleigh,NC 27699-1611
li _ •
is
13b.Disinfection type: I l k Amount: Si `V 1
Form W 1 •
• G
North Carolina Department ofEavironmental Quality-Division of Water Resources
. Revised 6-6-2018