GW1--07141_Well Construction - GW1_20231101

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WELL CONSTRUCTION RECORD (GW-1) ''r For Internal Use Only:
1.Well Contractor Information:
J1 L �-�! '!ir C�/ 14.WATER ZONES
Well Contractor Name c FROM -:TO DESCRIPTION
��i q 22 v O 25 ft ft.
ft. ft.
NC Well Contractor Certification Number //��J^^� 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
ti/e°eitei�// a Fie_
. FROM TO DIAMETER THICKNESS I MATERIAL
w+'/ �j(j(�EC. © ft. Zl f. I in-
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop) ', ,'
/v
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) /velft, ft. in.
3.Well Use(check well use): it ft. in.
Water Supply Well: 17.SCREEN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft in.
2�( l ft.
61.6to 61,124" Pile-
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: / 7 ft. r ft n A.tilQ 6446
jQlvlonitoring ❑Recovery ft! -_ ft --- _ _ - -
.- -- Injection Well:- -
ft ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage Zq ft C 7 ft SAP 6-24(//77
❑Experimental Technology 0 Subsidence Control R. ft /
❑Geothermal(Closed Loop) ❑Tracer '.20.DRILLING LOG(attach additional sheets if necessary)- - . •
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solUmck type,grain size,etc.)
O ft 1..- ft. SILL
4.Date Well(s)Completed: l0/y/7.3 Well ID# A I / 2, ft. zY ft. "Ate e t5A-o.4..� C_t'
5a./W�yell Location: ` [[[ 7 cf ft. 4 ft 6,4 s,� /4 cCirj
/V d'.-((04+r 1/ti e� ft. ft. ! }172 7 ,-j
1/n
ft. ft. I, u.�t. •,-.- r
Facility/Owner Nary e /,,, r Facility ID#(if applicable) 1 Nov"'i-,,.,i; �� lip-'.i
0 V ZL7 ittod I1 4/ly A� ft. ft. I I Y q1 2023
Physical Address,City,and Zip / ft ft.
bl eel kAbcf i31.REMARKS , :: l n.
County Parcel Identification No.(PIN) 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 1
r iS,G 7Z/ N -1°.,rsf e'>;!o W l6/�/z3
6.Is the well(s): ermanent or ❑Tern ora Si of Certified Well Coq ctor I' Date
Is(are)
' By signing this form,1 hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 1SA NCAC 02C.0100 or ISA NCAC 02C:0200{Yell Construction Standards and that a copy
If this is a repair,fill out known well construction information a explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
�j 24.SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: / (ft.) Submit this GW-1 within 30 days'of well completionper er the following:
For multiple wells list all depths ifd different(example-3 200'and 2@100') ,,
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.t,Z� / 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: `-�� (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
�// Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A'(/64 Z 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
•
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' • Revised 6-6-2018