GW1--03310_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 't/1► /(�
/r Yn 4 �/4J,a,, /a,L Cam' i l k,AQ/X,_ 14.WATER ZONES
Well Contractor Name MOSE ' TO N
7�- 39 75/-G 3 s n• 7/ n- u!/#'44 -�re!!aJ -mod_
NC Well�Co�actar Certification Number IS.OUTER CASING(for 0olu�sed wells)OR LINER Of a )
L.uA.4 Itiatti t-AdLlAdGj/l 3( X t'_ PROM ft. To
a DIAMETERDIAMETERTHICKNESSTHICKNESSss I MATERIAL
to.
Company Name // 16.IN NKR CASING OR TUBING(geothermal dated-loop)
2.Well Construction Permit#: ''T4?-S3 PROM i TO DIAMETER THICKNESSMATERIAL.
List all applicable well construction permits(i.e.Ul e.Variance.etc.) 'r"/ IL & IL !4'/ te' 5eA1. (f.1j 1OV
3.Well Use(check well use): \\\\ / 7/ D' 7 3 n- !4 r, _ c5 6 P 1/C-
'Water Supply Well: 17.SCREEN
)EOM TO DIAMETER SLOT SIZE THICKNESS SS MATERIAL
❑Agricultural ❑MunicipaUFublic 6 4,B. 7/ IL l / m- 6 6 3,,.?‘
$S
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ti rt. in.
❑lndustrial/Commacial iaResidential Water Supply(shared) 18.GROUI -
Dlnigation °Wells>100,000 GPD 1RWIi 1 To Jammu'. ' E MAC MI2ITMETHOD&AI4OuNr
Non-Water Supply Well: Q ft. 01/ 7,t 7� p a-cc
°Monitoring ❑Recovery tt. it.
Injection Well: • -
fer Recharge '.
i]A4Dt ❑Groundwater tailor 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery (*linityBarrier PROM ' TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage a/ ft' 7 3 IL .iC .r d+•V_ -
❑Experimental Techno ❑Subsidence Control ill R- 9
❑Geothermal 6 eel Loop) ❑Tracer 20.DRILLING LOG(attack additional sheets if aeeeasary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) PROMD�CltlR7ioN(O0t'r'� 't0ilhuck tit,tdams she,de)
d R Z� ". 731)
'S•et.I. as. (JA,fAte
4.Date Well(a)Completed: .5 7-IS Well ID# ZO IL
3.T r ft- M d a,Ayt Si11441
5a.Well Location: 3 ft. 7/ ft. t d1.4/.. S/F.,01.
cr--Cnlrtl!Y-eiL riliiZzy
• 7.,,, n. _I,d rt. lAi 1 /�i
Facility/Owner Name Facility 113#(if applicable)
/7751 ?use_%?)ufc_ We/ _04q-eitcS044 .S -S ft. it
Physical Address,City,and Zip �1 27Z.S/ n. It.
mGI6ny O` T 73d 5 2LREMARKs
County Parcel Idrorification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .y a �
(if well field.one tat/long is sufficient) I '/, Hon:8. 372-if'- .3 /` 0/-e
=`S' 'r I "/ N 7. e33 3T w Z,Aiid -3-oi-
zy
6.Is(are)the well(s):A1<rmauent or ❑Temporary Signature of Caged will Contractor Date
By signing this form,1 hereby certify'nat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this it a repair,fill out known well construction information erplain the nature of the of this record has been provided to the well owner.
repair under t2l remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed- eothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is . Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfaces /3 (f.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3®200'annd 41)100')
10.Static water level below top of casing: 42- (n-) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1 // 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i 1,U -;e0 4,7 i 24c-For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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,R:detgh,NC 27699-1 6 1 1
13a.Yield(gpm) �d" J Method of tech�,�
13b.Disinfection type: (.1/a/f/Q-i Amount �j 1'J
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018