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Home My WebLink AboutGW1--05630_Well Construction - GW1_20230831 ., . • WELL CONSTRUCTION RECO (GW-11 ( . •• �( For Internal Use Only: • ` 1.Well Contrac r•Information: ff 1 ' /" ' 3e I / eoh 7° a/�� ••14.WATER ZONES •1. Well Contractor Mine- y FROM TO DESCRIPTION • -` 3 S.J�S • . Ot` (,O( ft N Well Contractor Certification Number ft ft • 15.OUTER CASING(for multi cased inns)OR LINER(if ap livable) a/Yf/ FROM TO DI THICKNESS MATERIAL • Company Name �� I ft JAMETER I 39 L"��S 16.INNER CASING OR TUBING(geothermal closed-loop)2.Well Construction Permit#: - • FROM To DIAMETER THICKNESS MATERIAL List all applicable well construction permits ff.e.WG Cotmry,'State,Variance,eta) ././ ft 1.75( tt ,S 7%' m 3.Well Use(check well use): 31 (!�. pre:- . . ft. ft ' , in. Water Supply Well: l7•SCREEN ❑AgriculturalFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL AunicipaliPublic ft ft .., f in. ❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single)❑Industrial/Commercial tt (n' 'sidential'Water Supply(shared) 18:GROUT ❑litigation _ . - --.- DWells>100,000 GM): - FROM • TO - -MATERIAL - - EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: • 6 tt 13 "hint ' °Monitoring °Recove• ry • . ft. / ' `-l' d V Injection Well: j� , e4k 4 • /_�"f?' ❑Aquifer Recharge ❑GroundwaterRemediation• ft it ❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) • • FROM TO MATERIAL, EMI'LACEMENTMETHOD OAquifer Test . • . ❑Stmmwater Drainage . ' .. ft ft. ❑Experimental Technology - ❑Subsidence Control ft • ft • . 0-Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO • DESCRIPTION(solo;hardness,soil/rock type grain sae etc) �J fc • 4.Date Well(s)Completed: D 2 Z-L3 Well ID# . • ft •ft • 5a. ell Location: ft reitij • s a:. o r l ft. ft. • - • Facility/Owner Name f • Facility KW(if applicable) ft ft.• 1 2,UZ3 l fSfZ -- :a' NOG 3 / Z Z/ /U �'a fM e� - 6 Slap rh• tt rt • rRd`etalf A U,t'4t Ph i s,City,and Zip [AZ410114 ft. ft a Oltor'r41""6 eii sloG Jh CkiY • • 21.REMARKS/ • County J ux Parcel IdentifieationNo.(PIN) • 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • (if well field,one lat/long is sufficient) 1 ' 33 ' 32. N 87 ' 3 ' : . W 1 22.Certif�t 'on: x • / • • � sa. .2 3. 23 6.Is(are)the well(s): C P rmanent- or ❑Temporary_ 7L/, , Signature of Certified Well Contractor Date • a U By string tits form,I hereby certio,that the wel(r was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or it o ISANCAC 02C:0100 or'7S:1 NCAC 02C.0200 Well Construction Standards and that a copy "this Is a repair,fill out bourn well construction information anplain the nature of the of this record has been provided to the well owner. • 'repair under VI 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 is needed. Indicate TOTAL NUMBER of-wells. (add'See Over'in Reniarks Bo)9.You may also attach additionarpages if necessary. drilled:- 24.SUBMITTAL INSTRUCTIONS ' 9.Total well depth below land surface: `(it) . For multiple wells list all depths-((different(exaritple-3Q200'and 2(�1005 Submit this GW 1 within 30.days of well completion per the following: 10.Static water level below top of casing: / Q • (it) 24a. For All Wells: Original form to Division of Water Resources (DWR),• "water level Is above cas(n&!ve"+"!` Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • 11.Borehole diameter: ! 1( I ,(in•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) Program,1636 MSC,Raleigh,NC 27699-1636 12.Welt construction method: pia 1-9 _ (Le.auger,rotary,cable,direct push,eta) 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: • /,� k A 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 13a.Yield(gpm) Method of test:, Cv Permit Program,1611 MSC,Rale►gh,•NC 27699-1611 Iis 13b.Disinfection type: l� Amount: 1 f-� pi- • 7 0 Form GW-1 North Caroline Department of Environmental Quality,_Division of Water Resources t Revised 6 6 2018