GW1--03980_Well Construction - GW1_20240705

WELL CO RECO _ (GW-1) For Internal Use Only:
1.Well Coytrar tor.Iuforrpation: •
ir.
sz:471444....,.
i °G. 14.WATER ZONES
WouContractor Naaammm'',�� /'�G FROM TO -DESCRIPTION
` ✓ i -A SQ ft' C�O ft
ft ft.
NC Well Contractor Certification Number
/'' ,,
15.OUTER CASING(for multi-cased wells)OR LINER(if a 4nbte)
Gc.�nJ 5 e-c.)-t--3-1 -e_v S PROM I TO ft j DIAMETER TRIMNESS MATERIAL
Company Name tt in
•
16.INNER CASINO ORTUBING(geothermal dosed look
2.Well Construction Permit#: FROM TO DIAMETER TEEIC10fESS MATERIAL,List all applicable well corutruction permits(Le.UIC,County,Slate,Variance,etc.) -.E, 1 ft 23 fE, S ln,
3.Well Use(check well use): ft. ft.`, in.
Water Supply Well: 47.SCREEN
OA cultural PROM TO DIAMETER SLOTSIZE TSICIQ(LSS MATERIAL
❑Murucipal/Public ft ft ... in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft ft. in.
OlndustriaUCommercial ❑Residential Water Supply(shared) -
1E.GROUT
❑irrigation O Wells>100,000 GPD FROM TO �MATERIAL EMPLACEIKENT MI1HOD&AMOUNT
Non-Water Supply Well: D ft 2 ? ft ]V eR
❑Monitoring ❑Recovery ft• J ft*
t Y �/) i 1C-e�
' Injection Well: IUD t�1A+f f]
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVELPACI ffapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier .
PROM TO t hIATEAIAI, gMPiACFMLTIrRfEIHOD
❑Aquifer Test OStormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
• ❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional streets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explaintm�a ; y�FROM TO DLSCRII my(color,hardens,soa/nek type,gram sim etc)
` lJ ft ft
4.Date Wells)Completed: to 13_ 2-1 Well ID# V L. ft ft
� 20247 f�7 � , L ta ct 5 --10 6
5a.Well Location: J U L 0 e, ft. ft
Cl a I/T (/YN. I A(.YY) /1 ' ft ft
• Facrli /Owner Name p� .(T11i�A?.' rs WK.... \
ty � L ZI Faciliil ID#(r eabk)„ fG f� .Zf G/ t�m- 0c3 Ss!-e re�1
ASheCo • Meadow Creep. Rd .(l/( 1-9 )
Physical Address,City.and Zip Z V ft.
-
ASN 11.REMARKS/ •
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22 Ccr' c :
3 6 ' lr 3L ' N SI ' 31 ' Si ' W A ' 6 -/3_ Z
6.Ls(are)the well(s):YPermanent or OTemporary i Cj/�' Signature of larff T.,yell Contractor Date
ay
11 ll v By signing this form,I hereby cerr 5 that the well()um(were)constructed In accordance with
7.is this a repair to an existing well: Oyes or No ISAMAC 02C:0100 or'ISA.MAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill out brown well construction information explain the nature of the of this record has been presided to the wen owner.
'repair under#21 remarks section or on the back of that form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells haying the some You may use the back of the page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of weals (add'See Over'in Remarim Box).You may also attach additional pages if necessary.drilled:
/ 24.SUBMITTAL INS fRUC.TIONS '
b9.Total well depth below land surface: ' A.6 (ft)
For multiple welly list all depths jd�crent(example-3(aj.1W'and 2(a�l00� Submit this GW-1 within 3(1 days of well completion per the following:
10.Static water level below top of casing: C 24a. For All Wells: Original form to Division of Water Resources (DWR), •
If water level is above eosin •
(ft)
&jrre'+�/!`�J Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Vv` O {in.) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
i7 6 a r� /� Program,1636 MSC,Raleigh NC 27699-1636
12.Well construction method: R _ A. r.
(i.e.auger,rotary,cable,direct push,etc.) ` - 24c.For Water Supply and(feu-Loop Geothermal Return Wells:Copy to the '
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: •
C� 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of task i r Permit Program,1611 MSC,Raleigh,NC 27699-1611
_ 1,
13b.Disinfection type: 14 l/-I Amount: I 'L- it.
Form GW-1 North Carolina Department ofEuvironmeutal Quality-Division of Water Resources r._ • ., .-_.-