GW1--07069_Well Construction - GW1_20231103

WELL CONSTRUCTION RECORD GW-1
i• ' •; •. For Internal Use Orily';
1.Well Contractor Information: •
idrlfad,.M Meklizbge, By ,I I
14.WATER ZONES I I
Well Contractor Name PROM TO
I I DESCRIPTION
lft. MI !
ft. ft.I
NC Well Contractor Certification Number
,y 0�,mil. po FROM
CASING(for mucased wells)OR LINER(If ay likable)
oble)
I�L�+�•tr ea I DIAMETER THICKNESS g MATERIAL Name, . 8 H. ft,III in, I
2.Well Construction Permit#: �° �� 16.INNER CASING OR TUBING(geothermal closed-loop)
List all applicable well construction pe nits(i.e.'UJC,CainstjSta�Variiance,etc) FROM TO I DIAMETER THICKNESS MATERIAL
fL ft. in.
3.Well Use(check well use): Pet'✓+,g �.1 60 4s. ✓r e efL
ft. it. In.
Water Supply Well: 17.SCREEN I
DA •icultural , ❑Municipal/Publio FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL❑Geothermal(Heating/Cooling Supply) °Residential Water Su 1 ft. tt• 1 in
Pp Y(single) In.
❑Industrial/Comrnercial ❑Residential Water Supply(shared) I •
❑hrigation 18.GROUT i..; -
❑Wells,>100,000 GPD FROM TO
I M 1TERIAL''x EMPLACEMENT METHOD&AMOUNTNon-Water Supply Well:
• ft. ft. 1 '
:Monitoring ! ❑Recovery
•
Injection Well: ft ft• . i'
°Aquifer Recharge IrdGroun,dwater Remediation • tt• tt'
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(If applicable)•
❑Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
°Stormwater Drainage • . • ft. • it. I.
:Experimental Technology ❑Subsidence Control .
I. ft,
°Geothermal(Closed Loop) °Tracer • 20.DRILLING LOG attach additional sheets if necessa°Geothermal(Heating/Cooling Return) Cher(explain under#21 Remarks) FROM TO DESCRIPTION?color,hardness,soli/rock
I ss, type,grain sire,etc.)
4.Date Well(s)Completed!e•''R•-Z3 Well ID# %/ /,/ . 2 ft' �3 aerial�t��`i '�d'c iA 7
S7.D ." a� Ait.5a.Well Location: Mgx f st A. ��-�
/ . Owe-Hour 1, eves`-101-RmJLS.Ye 4(Chf9z%6igittv ft. • R. I
Facility/Owner Name
Facility IDS(if applicable) ft• ft, j t .�,
C�• i�o.� 3l✓ �>m�lll�•ile g� �d ft, ft. 1;
NO V ,<) t Z��3
Physical Address,City,and Zip �e t� /�-pft. • ft,
® �lB(A� 43 dII3D'O 81p 21.REMAR �..<:.,,..:
6➢65 .
County Parcel Identification No.(PIN) /� 'e t^ (e EA,s�s 'f ii� t O` ` `'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: geea.tie,- •411 ei.S'eh a-'*t"c ro g-C csd..sl r•io•eN0 F.,e1 et g as
(if well field,one lat/long is sufficient)
22.Certification:
6.is(are)thewells): ermanent or ❑Temporary ignaturcofC W✓. 4),:„...: . /O ,�-�
ell Contractor Date
7.Is this a repair to air existing WOW Likes, or Bysigning thisfornt,l hereby certify that the well(s)was(were)constructed in accordance with
!filth is a repuir,Jill out known well construction in/br ination and explain the nature of the o s record has been provided to die well own;Nell Corrsn rrclion Standards and that a cope
repair under#21 renmrkc section or on the back of this f'ornr, I
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 Ovei'in Remarks Box).Yciu may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:';: i'' ' 3 (ft.) ` '
For multiple wells list all depths it -!3Q100'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
I
10.Static water level below top of casing: ®p (fri) '24a. For MI Wells: Original forth rtu to Division of Water Resources (DWR),
If water level is above casing,use"+" information Processing Unit,1617I MSC,Raleigh,NC 27699-1617
II.Borehole diameter: Ca (in,) 24h.For Infection Wells:Copy to DWR,Underground Injection Control(WC)
i Program,1.636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i ®/'' .57 ' lPe i . I
(i.e.auger,rotary,cable;'direct push,etc.) 24e.For Water Supply and OpenlrLoop Geothermal Return Wells:Copy to the
•1 county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: l' l •
24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCIJA
13a.Yield(gpm) Method of test: Pcmtit Program,1611 MSC,Raleigh,'NC 27699-1611
13b.Disinfection type: Amount:
I •
•
Form GW-1 North Carolina Department of Environri�enlal Quality-Division of Water Resources ;
Revised F.(,:9n i a