GW1--00994_Well Construction - GW1_20240208

vvJP.ALL.t. JIN01IitUU11Ulr J.U1CUHU(CiW-1) For Internal Use Only: '
1.Well Contractor Information: JAai
l14- ‘I-1 "-Tic..,c c-sor '14AWATERZONES :'_
Well Contractor Name FROM TO DESCRIPTION
.2uC., ft.
.-2.�3 it ft. 1
NC Well Contractor Certification Number
- • 15::OUTERCASING`(for:multi•ca3ed WeRs)`OR LINER(if ap Iicable) . .
`N oV AV NI-Ye1 b r,\\`r`r+11 i+ •
FROM TO IMAM ER THICKNESS MATERIAL
Company Name 1 ft 3ft. j f ( in. t / I (..
e i .i6 INNER.CASING:ORTUBIN t(geotheriaeldosed]tiop)
2.Well Construction PI tihh (�Permit#: V I 1 CID FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(J1C,County.State,Variance,etc.) ft. ft. in.
4 3.Well Use(check well use): ft ft in.
Water Supply Well: 'l7 SCREEN: z :.
-" FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
` °Geothermal(Heating/Cooling Supply) "Residential Water Supply(single) ft. ft. ,in. -
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft it, r
TfPJ�IY\\� 'l�vb�e
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-.19 SAND/GRAVEL"PACK(if applicable) -:
❑Aquifer Storage and Recovery • ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. 1
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 2O DWLLING LOG(attrieh iidditloiial sheets_if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soWrocictype eraln sUc etc.)
6 ft. 10 ft r[3�•r
-b1 Cie.'
4.Date Well(s)Completed: 1 3 1I 2 4 Well ID# l b ft 100ft b iue_ 5 f a I e,
5a.Well Location: . '. ° n/ ft. ft. T
Ben Wo.r1tck. l:C 0e �.I1 ft. ft.
ft ft. a .� .,
Facility/Owner Name , Facility ID#(if applicable) t 'I` +_'..4 /�;')
ft. ft. 1 E s �.r
cN Ici Oak- 'rrnm& FEB d 8 2024
Physical Address,City,and Zip ft. ft.
Q - :21 REM ARKSi_
.?TG t1 i.1.1 Z O (...::: ;aP1C .-oftf.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,once hit/long is sufficient) 22.Cgertification:
p
6.Is(are)the well(s): 'Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or Cello ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
I
, repair under#21 rema b 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks BoxYr You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
/ a
9.Total well depth below land surface: 60 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2©100')
C� (ft) 24a. For All Wells: Original;form to,Division of Water Resources (DWR),
10.Static water level below top of casing:
a If water level is above casing.use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter ` On.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: k"\J" 4 C.-Y 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: N
24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2 Method of test: et\r Permit Program,1611 MSC,Raleigh,NC 27699-1611
•
13b.Disinfection type: I t 4 Amount: 1 P'In
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