GW1--05970_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECO ,(GW-1)• .For Internal Use Only: . , . •
1.Well Con c .Information: ' a
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• ' •14.WATER ZONES . I
Well Contractor _-•••
FROM TO DESCRIPTION
• L . q 7 --A- j 00 ft' 2.0.0 ft. G 1
NC Well Contractor Certification Number /� ft f' •/ l •I •
�rW V l J. . i-. 15.OUTER CASING(for multi-eased wells)OR LINER(if tip 4eable) - •
' d V + FROM I TO DIAMETER I THICKNESS MAIERrAI,
Company Name ft ft
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' 3 Z 16.INNER CASING OR TUBING(geothermal closed loop) •
2.Well Construction Permit#: 'Fait, 2D 8 /J P FROM TO DUMEITR TIUCENESS MATERIAL
List all applicable well conso ucnon permits(!.e.uza Corm%State,Variance,eta)
• t'1 ft Cod ft ✓d 'u• lei rrc L Pr'-'.,3.Well Use(check well use): • _ ft. , 1 in.
-Water •
Supply. ell: 7.SCREEN
OAgncuttnlal FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
7. 'OMunicipal/Public ft ft - in
❑Geothermal(Heating/Cooling Supply) 5--°Residential Water Supply single)
ft.. ft In'
Olndustrial/Commercial
OResidential•Water Supply(shared)
Olrigation8.GROUT p
ClWells>100,000 GPD FROM TO MA 'JiTUIAI..--EMPLACEMENT MX mOD:QeAMOUNT Non-Water Supply Well: 77 ft "Z-3 ft _____A.4' /
• °Monitoring . °Recovery --- ` �'
Injection Well:
t't n rf19 /
.. y�4
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°Aquifer Recharge ❑Groundwater Remediation ft ft �
°Aquifer Storage and Recovery (Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) •
FROM TO. MATERIAL EMPIACFMENTMETHOD
OAquiferTest OStormwater Drainage r - . ft ft . '
°Experimental Technology °Subsidence Control ft ft
• . (Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
O Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO. • DESCRD?T10N(color,hardness,soelirock typo die sae,eta)
ft ft .
4.Date Well(s)Completed: g 3l. 3 Well ID# ft. •
11.
5a.Well Location: ft. it
::/\clam •1- P a tid-ee Sum mews ft. (:, , it�1=-a
• .,Facility/Owner Name . . FaciityM#(if appliable) ft ft.
1-4 . G. L�,w:'s Or. ,_.t ft S �'.1 2023
Physical Address,City,and Zip ft. . ft '' . ll)6'Cie'iSs1•:Z n l7t'^::;kl..}?..g lire
_S (,1_.r t 9 21 REMARKS./ cfr:�:,• :0+y
County • Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees:
(ifwell field,one 1at/long is sufficient) 22.Ce I.
3G -a2 ' 37 ' N 'O ' 53 ' LJ3' w n` .1.
` a.
6.Is(are)the well(s): permanent' or °Temporary I 2-4 01 Signature of est• c'.'ell Conhactoc Ditd -
onn.!hereb Bye/piny/3f yw•�J'that the weU(s)wartSvareJ constructed inaecardmtcewide
7.Is this a repair to an existing well: °Yes or : l io • MA MAC 02C:0100 or IS;!MAC 02C.0200 Well Cviurtuction Standards and that a copy If this is a repair,fill out brown well construction information and drplain the nature of the 'ofthis record has been provided to the well owner.
'repair wider 821 remarks section or on the back of thisform. -
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 Over'in Remarks Box).you may also attach additional pages if nrePcrary.
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drilled:
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24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: (ft)
Forma Up/e wells Ust all depthr►ifdi�er'ent(eranpk-3()a 200'and 2(a)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: G 6 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),• I.
Ijwoterlevel is above easing:use"+' . Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
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11.Borehole diameter: to 1-51 ,(m,) 24b.For Infection Wells:Copy,to DWR,Underground Injection Control(IUC)
.' R 1 n I Program,1636 MSC,Raleigh,NC 27699-1636
12..Well construction method: bT a Ili AY- 1 G _
(i.e auger,rotary,able,direct push.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: 24d.For Water Wells prodacini:over 100,000 GPD:Copy to DWR,CCPCUA '
13a,Yield'(gpm) � • Method of test: /^l K • Permit Program,1611 MSC,Raleigh;NC 27699-1611'
13b.Disinfection type: ti 1 la Amount: b2 0 •
Form GW-1 . North Corolla;Department of Environmental
Quality-ty-Division ofWaterResmaees - Revised 6 6-2018