GW1--04952_Well Construction - GW1_20230807

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WELL CONSTRUCTION RECO (GW-1), For Internal Use Only: .
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• 1.Well ctor•Information:
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•14.WATER ZONES
Well Co arN FROM TO DESCRIPTION
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ft. ft
NC Well Contractor CeRifieatronN er • 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
TbIliffrh.
/e w,. �, FROM TO DIAMETER TSIC[ONESS MATERIAL,(/�'v V ft fG in.
Company Name z u/ 1� 16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: •✓ v l ✓ La Z • FROM TO DIAMETER, THICKNESS MATERIAL
List all applicable well construction permits(I.e.MC Comrry,State,Variance,Us) +i f ft-3I ,g. .5 ' 777f r 4t D
3.Well Use(check well use): ft. • R is J
Water Supply Well: 7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• oAgriculttlral Municipal/Public ft _ ft _ is
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft in..
❑Industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT
❑Irrigation /1' v❑Wells>_IU0000 GPD, FROtiI TO MATERIAL EMPLACEMENT METHOD& OUNT
Non-Water Supply Well: U ft 23 ft: Al t ct.1" M .
e l
• ❑Monitoring ••
❑Recovery ft. le' '1)d r 1 F4_74
• Injection Well: •
ft ft. f L1 1`L' 1'��
❑Aquifer Recharge ❑Groundwater Remediation 1
❑Aquifer Storage and Recovery . . ❑SalinityBanier • • • FROS�ND/GRTO LPACIC(MMAATpRIALe)
EMPLACEMENT METHOD
❑Aquifer Test OStormwater 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) °Other(explain under#21 Remarks) FROM TO • DESCRIPTION(color,hvdaess soil/rocktrpe vain sire etc)
f q ft. ft
4.Date Well(s)Completed: 7 l 1-G 3 Well)D# ft. •tt;
Sa ell Location: ft. •• ft. F.1-.1: h
, . - a-Frr c- AI ft
• Fact'hty/Owner Name eland. Facility ID#(if applicable) ft. if�j �d ..Zaz3
-I- i e \-- Ors reek. - -'• ft
Physi ddress,City,and Zip !t ft lam`'" MC5 v
,2L REMARKS.(:
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Ewell Held,one lat/long is sufficient) 22.Ce II;
•31' 30.' 33 N 8/ ' 31' 5b' W .� � 40,14:14c. 7,,31_Z3
6.Is(are)the well(s):..0 rmaaent. or °Temporary7�� Signature of e ell Contractor Date
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Bysigningthifotm,Ilhereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or , o. ISA NCAC 02C:0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out barman well construction information d lain the nature of the of this record has been provided to the well owner.
'repair under#21 remarks section or on the back ofthisform.
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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Rdniarks Box).You may also attach additional pages if necessary,
drilled:
• 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: 3 26 • (ft)
For multiple wells list all depths((fdrerent(example-3t200'and 2 a@100' Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original- form to Division of Water Resources (DWR),•
Ifwater level is above caring;use•*-1.? Information Processing Unit;1617•MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter. /9 S .(in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rota
ta Ayr--
Program, MSC,Raleigh,NC 27699-1636
12.Well construction method: / /�[y}�
(ie.auger,rotary,cable,dneetpusb,ere.) - 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 DWR,CCPCUA
13a.Yield(gpm) .I' Method of test. C2.-VL. • Permit Program,1611 MSC,Raleigh;NC 27699-1611 . •
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13b.Disinfection type: (�1l ?C> Amount: 9 no-
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'Form GW--I • North Carolina Department ofPnvimne,e,.ret n...,r..._nr.:_:-- - '