GW1--05840_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECO
(GW-11, For Internal Use Only:
1.We n ctor•Information• V I •
. • •14.WATER ZONES : i
Well Co
•
We
FROM TO DESCRD*rION —
• • t 5917A •
ldoft' ct-o ft 1 _
NC Well Contractor Cation Number ft ft. I.
cwN�/ 1,,��.,.Q n 15.OUTER CASING(for multi-cm wells)OR LINER(ifap linable) •
I V 1 f1�P/L �X/s .'� FROM DIAMETER TSICIOVFSS 1 MATERIAL
CompanyNamc R I ft.l i',
2.Well Construction Permit it: .l D 1 16.INNER CASING OR TUBING(geothermal doted-loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consnsrctlon permits 0.e.UlC,Cowry,State,Variance,etc) ft.
fk. in
-t 1 21 �/� Th „. P
3.Well Use(check well use): ft •
ft 'j, is
Water Supply Well: • V.SCREEN
OAgr cultural FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL❑Municipal/Public ft ft.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(sin e - to
81) ft ft
❑IndustrialJCommercial ❑Residential'Water Supply(shared) • •
❑Irrigation 18 GROUT I i
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - ' D ft. Z3 ft
❑Monitoring • ORecovery • ft "-�•�eft / '/` ; l� {a
Injection Well: ft `YnYB %�Ltin-y, .4
°Aquifer Recharge • ❑Groundwater Remediation •
ft ft
•
•
❑Aquifer Storage and Recovery ❑Salutity Barrier •
19.SAND/GRAVEL PACK(if applicable) •
FROM TO MATERIAL EMPLACFMENrMETHOD
❑Aquifer Test. ' . • ❑StormwaterDrainage ft ft '
❑Experimental Technology ❑Subsidence Control ft ft • •
❑Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
•
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) FROM TO • DESCRn'TI
. ON(color.hardness,soVmek type.train size.etc.)
O
p ft.
!
4.Date Well(s)Completed: -2-13 Well ID# • ft. .ft'
-e'�I Gt.0 P wi e n�" uo-ell
5a:Well Location: ft is
'Loire i-ct, 14 . 11 ft V'�;
• Facility/Owner Name FatalityID9(if appliable) ft ft l�'`'" '�
22 5 U 3 s m t�-t- Lk) -. B oo - t t'kl .'ft f� 5t� J ? 2023 •
Physical ddress City,and Zip ft'a}Q 21.REMARKS! [}t!'t?7Q` a
County eJ Parcel Identification No.(PIN) • b •
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: •
(ifwell field,one lat/long is sufficient)
3L1 1 fe.' 37. N '5i' 5 • 2ace „ ,,
`} 1 5 W • . t a,_.- •
'� 2 S _ 2 3
6.Is(are)the well(s): Permanent or ❑Temporary Sigoabrrb bf ell Contractor1 Date
By signing this form,thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or Ao • ISANCAC 02C:0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!phis is a repair,fill out knownwell construction information and explain the nature of the . elks record has been provided to the well owner.'repair under 92!remark section or cn the back of this form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closes-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'is Rrniarks Box)-You may also attach additional pages if necessary.
• drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � ft ' •
For multiple wells list all depths ifdiperent(erampk-3Qa and d 2Qa 100� ( ) Submit this GW-1 within 30 days.of well completion per the following:
30.Static water level below top of casing. 8iJ • (n) 24a. For All Wells: Original form to Division of Water Resources (DWR),•
• If water kvel is above uvinp:use"+-(`f Information Processing Unit,1617IvISC,Raleigh,NC 27699-1617
11.Borehole diameter: r/O ( ) •
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
an• Program,1636 MSC,Raleigh,NC 27699-1636
12.Wen construction method: ►2Q`I 1d All".
(i.e auger,rotary,able,daatpush,-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:
nn - •
. 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 � Method of test: am.- • Permit Program,1611 MSC,Raleigh,N •
C 27699-1611
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13b.Disinfection type: H 1 IA- Amount: • t . .
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Form GW 1 North Carolina Departoltmt of Environmental Quality.Division of Water Resoraees
• Revised 6-6 2018
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