GW1--05934_Well Construction - GW1_20230918

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
eittlt P '. aensie1 14.WATER ZONES
Well Contract r Name FROM TO DESCRIPTION/14S n. aS�1L
't 9ph
3cft ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LLNER(if op licable)
FROM TO DI&WET R THIC'NESS MAT IAL
N 'nsIGYIS ltlltl De',ill Nc( I„G• l it II '{p I in •�iil0 /Wc. /
Company Name ` U , 1 DIET,
` `•( Art a - Q.t i v•ACesk,/
16.INNER CASING OR TUBING(geothermal closed-loop) CJ
2.Well Construction Permit#: 3 -11 q.5 FROM TO DIAMETER TIUCKNESS MATERIAL
List all applicable well construction permits(Le.U/C Court.State. t,rriarcr.etc.) R. rt. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN /V l
-
FROM TO DIAMETER SLOT SIB THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. rt. in.
❑Geothermal(Heating/Cooling Supply) $Residential Water Supply(single) n. R, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) iti.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D R 3 ft , V
❑Monitoring ORecovery
3 a 0 I e :111 I i)1)
injection Wen:
iL n.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(it-applicable)
flAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage I n. ft. ,
❑Experimental Technology ❑Subsidence Control it. f-
❑Geothermal(Closed Loop) ❑Tracer 2LL DRiLLiNG LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) UOther(explain under#21 Remarks) FROM lam`` DESCRIPTION(color.hardness,soil/rock t��.grain size.etc.)
O R. T� ft. ' rie..4 Set 1
4.Date Well(s)Completed:ft/o' 1,41�3 Well iD# 39 3,i q S 1,..4.0' S O n ✓G_ A
5a.Well Location: 666 go
IL 9 0 n r,K l.et Cl$
�Qf t L� I s S + . O oft. alp-ft- d�,il �,r�.ANA,`i-,-c__
Facility/Owner Name Facility iDil(if applicable) ft. ft.
t-1 i go /4 t". 3Q firs.,`r/ vidtr604,1 /JC, a.-s S-51 rt. IL t .i 1 t-_-_
Physical Address,City,and Zip R S E P 1 8 2023
*in CV, 032.c 0101 - 3l.RE,1ARKs
County • Parcel identification No.(PIN) In`::iul', "1 "gl'-.:•4•744:'3 Ur:,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
D C.C.OG
(if well field,one lat/long is sufficient) 22.C cation
,3(a. noZCI( $I 1 iN 7 • 5---. OI(g w 1` .
6.is(are)the well(s):$Permanent or ❑tfemporan Sigoa 'of rtified 1 Contractor Date 't �
Ur signing this%wnn.I hereby certifi•that the url/(s)was corral constructed in accordance uithn
7.is this a repair to an existing well: ❑Yes or No ESA A'CAC 02C.0100 or 15.4 KCAC 02C.0200 Well Coavructiou Standards and that a copy
If this is a repair.fill out known well construction information and explain the nature of the 41 this record has been provided to the well otter
repair under iI21 remarks section or on the back of this fora.
23.Site diagram or additional well details:
3.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dnlleu: / 24.SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: oro?8S- (ft.)
For multiple wells list all depths if different(example-3@200'antd 2(b2100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: o�O at)
fL information ProcessingUnit,1617 MSC,Raleigh,
If miter level is above casing.use"+" NC 27699-16(7
I I.Borehole diameter C., (in.) 24b. For Injection Wells:Copy to DWR,Underground injection Control(iUC)
Program. 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r'9/Q RO -2' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e auger,mtary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 2411.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCUA
13a.Yield(gpm) Method of test: /�/(JCS, Permit Program, 1611 MSC.Raleigh,NC 27699-1611
I3b.Disinfection type: dip ,/ Lair Amount: 2 D
t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201s