GW1--05152_Well Construction - GW1_20230814

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WELL CONSTRUCTION RECO tGW-11
• For Internal Use Only: •
1.W 11Contract r•Information: I
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. 1 •14.WATER ZONES - , 'ellCoat:aetorName FROM TO _•_•
• 3 S3 .5 . ft ft DESCRIPTION
17o 30 0
NC ell Contractor CeetisacoaNumber ¢ -
y� `/a IS.OUTER CASING(for multi-cased wells)OR LINER Map livable)
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ri JG(/YL in�Tl,4j_J' FROM TO DIAML�'TER • ICIOYESS MKI'ERIAL
Company Name "(�I--•„JJJ ft I ft I in.
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2.Well Construction Permit#: �, l W L d,n23 6�j�l 16.INNER CASING OR TUBIlNG(geothermal dosed-loon) •
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I a flltry Count'Slate,Y once etc.) -t./ ft /6
3.WelI Use(check well use): r �ft '.�' �� im 'nl�� �rL
it ft. in.
Water Supply Well: • .17.SCREEN
❑Agricultural 0Mlmicipal/Pub1. FROM TO DIAMETER SLOT SIZE THICKNESS MATERW,
1 it ft _ in.
❑Geothermal(Heating/Cooling Su
PP Y) idential Water Supply(single)
❑Industrial/Commercial . ❑Residential'WaterS lft ft ia'.
Supply(shared) 18.GROUT
❑Imgation ❑Wells>100,000 GPD FROM TO
Non-Water Supply Well: T L EIIB,I{A . .e METHOD&AMOUNT
• ❑Monitoring • ❑Recovery CsL� ,V` �Y�
• Injection Well: ft
r• ha ,t,,,t' p
❑Aquifer Recharge ❑Groundwater Remediation ft. ft
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) • •
FROM TO MATERIAL xrakacnrerr METHOD
0AQuifer Test ❑Stormwater Drainage 1 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#21Remarks) FROM TO DESCRIPTION(colon hardness,ss0/raaktype.grain smeate)
b ft ft •
4.Date Well(s)Completed: i'''7'-23 Well IN • ft .it. .
Sa.Well Location: ft. ' ft •
tt •
ft ft. }Y9ti _.P
• Facility/OwnerN e ` [1!: lj j_
Facility MI,(if applicable)
, ' ft. ft' AUGq q
7 r-) Col l rn 5 L l'7 - Ai- ► rL ft ft U � ..LOLJ
Physical Address,City.and Zip
MARKS./ CiMLtL.Xz
County Pared Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatOong is sufficient)
22.Ce • cation:
31, 36 /4-• N ge ' 32' 2;4 w
Aprei.
6.Is are the wells• 23
( ) ()•Armament• or OTemporary �/ / 'SignahuebfC 6:WellContnetor� '�
/ T�Q Bysigning this fonn.lhereb that the wels war Date
7.Is this a repair to an existing well: ❑Yes or l io . 1SANCAC 02C:0100 orI5AN!C 02C.0200 Well Constructioner Standards accordance with
If this is a repair,fill out blown well construction information andarplain the nature ofdie ofther record has been provided to the well owner-
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repair under 821 remarks section or on the back of thisform.
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: .:326 (ft) '
de
pths epths Ifdlfferenr(example 3@200•and 2Qa 100� Submit this GW-1 within 30 days of well completion per the following:
Formultlp/e waifs Est a
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10.Static water level below top of casing•. (j� • ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),•
Ifwater level is above aria&;we//�+- ` Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter. t)ii .Cm.) • 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
J ^ ►" Program, MSC,Raleigh,NC 27699-1636
12.Well construction method: D%a,y r/'rr
(ix.auger,rotary,cabin,direct 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
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13a.Yield(gpm) 31) Method of tests. ' •
Pit Program.1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: 1 ki14 • Amount:
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Form GW=1 North Carolina Department ofEavironmeatal Quality-Division of Water Resources Revised 6-6-2018