GW1--05631_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECO (GW 11 For Internal Use Only: !. •
1.WellCo I
or.Infornlatioa:
frei-g
Well Contract N •
• 14.WATER ZONES I' _
FROM TO DESCRIPTION
5 ?7./-r i . ft' Sao ft 1 _
NC Well Contractor
Certification Nu�mbbJer� ft. t� .
7211.412746
/%��/4'!/r''"C�? /, A/2.f) �i' 15.OUTER CASING(for multi-cased wells)OR LINER(:[apeL"eablo) •
FROM TO II/AMETEK in-
I THICKNESS I MATERIAL
Company Name ft �' ft I 1
• 16.INNER CASING OR TUBIN (geothermal dosed-loop)
2.Well Construction Permit#: FROM TO THICKNESS MATERIAL`
List all applicable well construction permits(i n UIC,Cou nry,State,Valiance,etc.) J f. CI
j/ ft' •i 77 / in. 7 le
� Dr�
3.Well Use(check well use): ` ft I� ft ' I o in. •
Water Supply Welk 417.SCREEN •
❑Agricultural OIvitmicipal/Pub1fC FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
CI Geothermal(Heating/CoolingSupply) DResidential Water Supply(single) ft. ft. ,_ ; in.n
!rpPY ft ft. .
OIndustrial/Commercial CResidential'WaterSnpply(shared) • •
OIrrigatiott 18.GROUT ;• •
OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD d&AMOUNT
Non-Water Supply Well: d ft 2 3 m A,0', 4�
• ❑Monitoring ❑Recovery • ft. ft /V l� /"`'��(-r�
Injection Well: �Or^H ^� p•
anti•✓�
DAquiferRecharge ❑GroundwaterRemediation it. ft
OAquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) • •
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStonnwater Drainage - ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
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• ❑Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
O Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRiPI10N fcotar,hardness,sa0iroek type.wain she eta)
�/ R ft
4.Date Well(s)Completed: O -//. 23 rim# ft.' it ''
5 llLo lion: • LOt' ft • • ft.
tP-R ( Th s) Co ,tLG -0-77 ft .ft s t ��••
• Facility/Owner Name 1� p
Facility ID#(ifappliable) , it R
221-1 G - MtNNwUGrPCIt - Amber/ 23
--ft. ft �, ,llG 3 a 20
Physical Address,City p D�-•� ft. rr 9,3 L!r•4
2L REMARKS./ ►ia� OJ:-,-"
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,'
(if well field,one 1at/long is sufficient)
22.Certifi •
`f. W •
� � >, $.2 S 23
6.Is(are)the well(s): C1Permanent or ❑Temporary 1• Signature ofC • !Il Contractor 1 Date
��Q Bysigningthisoonn,Ihereby cernfy that thewell(s)wai(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or / 3' iSA NCAC 02C:0100 or.14 NCAC 02C!0200 Well Construction Standards and that a copy
If this is a repair,Jill out brown well construction information and explain the nature ofthe of this record has been provided to the well owner-
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repatrunder#21 remarks section or on the back of this form.
23.Site diagram or additions 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 Rdniarks Box).You may also attach additional pages if necessary.drilled:
77 24.SUBMITTAL INSTRUCTIONS •
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9.Total well depth below land surface: (ft) •
For multiple wells list all depths IIfd�erent(example-g(a3200•mtd2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing-. D •
. (ft) 242. For All Wells: Original form to Division of Water Resources (DWR),
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Ijworer level is above casia&;vse"+i t/ •
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: 1 /b ,(.) • 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IOC)
j 7a-a wl Am_ Proglam,1636 MSC,Raleigh,NC 27699-1636
12.Weft construction method: I` -/1 T'
(r a auger,rotary,cable,direct push.eta) 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
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county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: • f 1
r 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) c7 6 Method of test (lam Permit Program.1611 MSC,Raleigh,NC 27699-1611 %
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13b.Disinfection type: 07-14 Amount: ', I0 Ct.--- ' 1
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- Form GW-1 North Carolina Department ofBnvitoemental Quality-Division of Water Resources Revised 6 6 2018•
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