GW1--04950_Well Construction - GW1_20230807

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WELL CONSTRUCTION RECO _:(GW-1) For Internal Use Only:
• 1.Well Co to o do ' I I •
14•.WATERZONES
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WellContac rName FROM TO
DES,CRPrION
• 4- ?7A 7Sft !G ft
NC W Contactor Certification Numb ft it
air('
15.OUTER CASING(for multi-cased wells)OR LINER(ifap limbic)W� FROM TO DIAMETER THICKNESS MATERIAL
Company Name �/ ft ft I I
2.Well Construction Permit#- S�o^f b G ! 7- •
16•INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICENFSS MATERIAL
List all applicable well construction permits(l.e.WC,Cormy,State,Variance,etc.) ••t! ft. / 5 ft 5* in Th 'C
(P ti Pn�
3.Well Use(check well use): ft ft - i •
Water Supply Well: • 47.SCREEN •
❑A Cultural FROM TO DIAMETER SLOT THICKNESS MATERIAL '•❑Mtmicipal/Public it. ft. in.
❑Geothermal(Fleating/CoolingSupply) idential Water Supply(single) -
❑IndustriaUCommercial ft ft in.'
❑Residential•Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • D ft z3 ft )0Tenct,7L• ❑Monitoring ❑Recovery ft /"'t p d`�
• Injection Well: ft 1�)' T�t1/ cat /
L.
❑Aquifer Recharge ❑GroundwaterRemediation ft.. it ` ( `
19.SAND/GRAVEL PACK(ifapplicable) •
❑Aquifer Storage and Recovery • ❑SalinityBarrier
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ' it ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
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• ❑Geothermal(Closed Loop) OTracer 20.DIMLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROMft. TO it • DESCRD?7ION(color,badness soil/rock type,coin size.eta)
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4.Date Well(s)Completed: 7"Z S�23 Well ID# • ft °tt r..i E . E' i 2a.,.r
Sa.Well Location: ft ft E Z.L.. "i,:. 4•, 11.Lel
an L'enff� ft. ft .
VAUG 0 71013'
• Facility/Owner Name Facility ID#(if applicable) ft ft.
13 aCln, kit ar /�GY-e s L r- •• .•ft . ft Ir<<:.(:(::� p',r,R��� tl,1
Physical Address,� City,and Zip ft _ +•ram
�/s-�'r"� f t
21.REMARKS/
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County Parcel Identification No.(PIN) • •
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lrr +7at long is sufficient)
/ tT e d ,• � , 31 22.Certifi .
6.Is(are)the well(s): ❑Permanent• or ❑Temporary 3 2 O D� Sigma ofC•., e el Cont Date
actorZ 3
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7.Is this a repair toan existing well pl(es or L�iQo By signing this form,Iherebycernfy that the weli(s)was(were)constructed in accordance with
ISANCAC 02C:0100 or=NCAC 02C.0200 Well Construction Standards and that a copy
!Phis isa repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
'repair under#2l 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 1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
j J) 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: / 6 vv (ft)
For multiplewells list all depths ifdfferent(example-3Q200'and2©100) Submit this GW-1 within30 days of well completion per the following:
10.Static water level below top of casing: l Q •-(ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), '
liwarer level is above caring;;use +� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter. G ,(n,) 24b.For Injection Wells:Copy to DWR,Underground
2 Program,1636 MSC,Raleigh,NC 27699-1636 Injection Control(IUC)
12.Welt construction method: � (��a-:�'4 - /./�•y1 �. .
(i.e auger rotary,cable,direapush,etc.) 1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the '
• county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000•GPD:Copy to DV/It,CCPCUA
13a.Yield(gpm) 0 Method of tech • Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: I A/1 .'
Ms
Amount •w
70 .
'Form GW-1 North Camlioa D apartment ofRavironmeutal Quality-Division of WaterResoumes
Revised 6-6-2018