GW1--05633_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECO
(GW 11 . For Internal Use Only: f
1.Well Contrac r. ormation• I
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•14.WATER ZONES .
Well CorrtraetorN' e'
FROM TO DESCRIPTION • - •
• 14-517—A too it' �,ZO ft: I .
NC Well Cou rtneta Catifieatioa Numb ft ft
15.OUTER j'n CASING(for multi-eased wells)OR LINER Crap 4eable) •
• FROM I TO
I DIAMETER I TJUCIOYESS MATERIAL
'. Company Name ft ft'
is
2.Well Construction Permit#: % !� 16 INNER CASING OR TUBING(geothermal closed-loop) •
List all applicable well construef/o# e n its e./UI 0, •'FROM TO' DIAMETER THICKNESS MATERIAL
P (+ c Cowl State, arianee,eta) "t.1 R Sib ft , C 76 j m' l pre-
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3.Well Use(check well use): , , /'Cl.
ft. k. � is
Water Supply Well: .17.SCREEN '
❑Agricultural OMtmicipal/Publjc FROM TO DIAMETER SLOT SIZE THICIOYFSS MATERIAL ' '
it ft _ L.in.
❑Geothermal
(Heating/Cooling Supply) AIRtsidential Water Supply(single)
❑Industrial/Commercial ft' ft. c•in.'
idential'Water Supply(shared)
❑Irrigation Res 18.GROUT � � - .
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD dcAMOUNT
Non-Water Supply Well: •
0 ft' Z3 ft lUea t-
• ❑Monitoring ❑Recovery /V`'���(
• Injection Well: ft. ft
❑AquiferRecharge . grfk�' (.Lry.,� - -
OGroundwaterRe.mediation ft, R
OAquiferSWrage and Recovery ❑SalinityBarrier 19•SAND/GRAVELPAQCGfapplicable) •
°Aquifer Test FROM TO MATERIAL EMPLACIIHEN!METHOD
❑SfolmwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control '
• R ft.
❑Geothermal(Closed Loop) ❑Tracer
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remadrs) PROM TO • DESCRIPTION(color,hardness,soil/reek typo pia size,eta)
ft. ft
4.Date Well(s)Completed: O—1(► 6-23 Well/D# ft •it.
Es.Well Location: Ir •t. ,. .
ft. ft
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• Facr'lity/OwnerN e ' ��,
^ Fac�7ityID#(ifapplipble) , ft. R. . • ! i 2��3
Cd Yu� Z -..ft ft a
Physical Address,Ci ,and Zip . " Z ' ft ft-
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I k'�so, pnr?{CrG`J f'� {+f'c.
p�j(�u1
21.REMARKS!
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County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
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• (if well field,one lat/lloong is sufficient)
3 e< Y r N i i r •22.Ce on:'4 . 0 8 I 3p 1 W
6.Is(are)the well(s):J?ermanent or ❑Temporary ( 3 o Si bf • -2,� Z
1 ill✓✓✓a 1�"maoro • Date
7.Isthisarepairtoanerastingwell: ❑Yes or y_u�0 Bysigaing Is form,Iherebycertify that the wel(r)war(Svere)constructed inaccordaicewith
IOW is a re ♦ 15ANClC 02C:t)!00 orl5;!NCrlG02C.0200 Well Construction Standards and that a copy
f pair,fill out known well construction information and explain the nature of the ofthrr record has been provided to the well owner.
'repair wider 421 remarks section or on the back_of this form. -
• 23.Site diagram or additional well details:
S.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 Rdmarks Box).You may also attach additional a
drilled: pa�esifnecessary.
24.SUBMITTAL INSTRUCTIONS 6
9.Total weft depth below land surface: G:�.a • (ft)
Formalrip/e wells h'st all depths ijdifJerent(ezample-3@200'and 2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing: 8d (ft) 24a._For All Wells: Original for* to Division of Water Resources (DWR),'
Ifwater level is above casing:use.++" . Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: G/` (in.) •
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �R Q'�a N �' 1
(Le.auger,rotary,able,direct push,etc,) ' 24c 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: •
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24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 13a.Yield(gpm) l • ' Permit Program, MSC,Raleigh,NC 27699-1611 s
Method of teak • 1
13b.Disinfection type: R/I
! t� Amount !- ft--- .
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Fotmcwl
' North Carona Department of Environmental Quality-Division of Water Resources i Revised t�2018
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