GW1--05781_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECO (GW-11
, For Internal Use Only: ,II,.
• 1.Well C tractor. rmatio
Well Contractor Nam •
•e `14.WATER ZONES .P '
FROM TO DESCRIPTION
• 3 S3 5 • ga ft' gad ft J
NC Well Contractor Certification Number ft it
J.
15.OUTER CASING(for multi-eased wells)OR LINER orap liable)
G
COmpany Name ,2 FROM I TO DIAMETER I THICKNESS MATERIAL
ft. I !I is
2.Well Construction Permit#: • 7 A 16. R CASING OR TUBING(geothermal C d ) .
List all applicable well construction ernt/ts e.III CounyFROM TO DIAMETER MATERIAL
P C Stale.Parlance.eta) 4 , ft CiZ ft Alle in.
3.Well Use(check well use): : D s P L'
ft ft. in.
Water Supply Well: �' •
,17.SCREEN •
OAgricultural OMtmicipal/Public FROM TO DIAMETER- SLOT SIZE THICKNESS MATER/AL
❑Geothermal(Heating/CoolingSupply) ft ft. _ , in.
PPY) sidential Water Supply(single)
OlndustriaUCommercial OResiden . ft ft in.'
tial'Water •Supply(shared) • •
❑Irrigatiop 18 GROUT
OWells>100,000 GPD FROM TO MBA./AL EMPLACEMENT METHOD&AMOUNT
Non-Wotrin Supply Well: Q 8 2.3 ft Neal �+ •
xq�
g ry
—•-Injection Wc:1:--- ._._: ORecove — — — —ft
• OAquiferRecharge- OGroundwaterRemediation ft, ft I!
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OAquifer Storage and Recovery OSalinity Harrier 19.SAND/GRAVEL PACK fdapplicable) •
°Aquifer Test FROM TO MATERIAL >ibiPL►CEM1'NrMETHOD
OStolmwaterDrainage ' • ft- g
❑Experimental Technology .OSubsidence Control ' ft ft '
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°Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)OGeothermal(Treating/CoolingRetum) ❑Other(explain under#21Remarks) FROM TO DESCRIP110N(color,bard ue�s,so0/mekrypa grain sae,etc)
' ft ft _
4.Date Well(s)Completed:A 3 0 •2e3 Well ID# R
• 5a.Well Location: 70 g P1 S/sv (�Ltn.,,,
• ft '' oh er-say, d1/l t -
anas L/olIL ft ft N e . •.
• Facility/Owner Name ' . - " • Facility ID#(ifapplicable) " • ft • g
Cre5+ Vi -e.W iuh-), .Or. err nc•� --ft
. ft" E. 4i1,'
Physical Address,City,and Zip Ale'
( R SEP
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ait_t!� ,v 21.REMARKS! SEP 0 5 -20 County I']Li� • C ll��Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' i in efOlZ,4v:iC.il'of' wa1 (J • ' • -
(ifwell field,one lat/long is sufficient)
ry� t�as
3 L 33' 22.Certification:
��1 N $G ' SSG ' .5? •• W , g_3 _
6.Is(are)the well(s): BPermanent or OTemporary Z 3
3i f W ����d Date
7.Isthisarepair2oanexisting _Byl'Igningthisform.Iherebycerti,that the well(s)war(were)constructed lnaccordancewith - -
well: DYes or elgi- IDANCdC 02C:0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
'repair under#21 remarb 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 Ovet in Remarks Box).You may also attach additional pages if nriu-se.ty drilled:
24.SUBMITTAL_INSTRUCTIONS •
9.Total well depth below land surface: r�0 d • • (ft) V ,
For multiple wells list all depths((different(example-3@200'and 20100) Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing. . (h) 242. For All Wells: Original'form to Division of Water Resources (DWR),•
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Ifwater level is above car/n&;we^�/^(/ •
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 :
11.Borehole diameter. �i ref On-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) '
Program,1636 MSC,Raleigh,NC 27699-1636 • '
12.Well construction method: �p t a,ri1— '
(ter auger.rotary.eablo,direct 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: , •
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24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
132.Yield(gpm) 2_n Method of test: ,� • Permit ► •
t Program, MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H 14 . Amount: g 'h.,' • •
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Form GW 1 North Carolina Department ofEnviro
t?lQualiry-Division of WataResourees Revised 6-6 2018
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