GW1--01317_Well Construction - GW1_20240229

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WELL CONSTRUCTION RECO _ (GW-1) For Internal Use Only: ,• , ' •• '
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I.Well Co ;Information:
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• • • • - •14.WATER ZONES . I ,•
'5141° FROM TO DESOMPTION
Well Contracior N.....6' .
. • 7..i;0 ft.• /40 ft. 7.! .
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174-.5 q 7 , •
. ft. " ft NC Well COnbietor Certification Number .
.15.OUTER CASING(for multi-cased wens)OR LINER(if au amble) • .
Py1,7 ....N.,„„,...e . - FROM I To . • DIAMETER I THICKNESS MATERIAL ,.
ft. ft. . ' in. •
Cc;ropany Name ' .
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, , A . 16.INNER CASING°RIDDING(eo thermal doted-loon) •
2.Well Construction Permit#: ' ."/-G,•I.2. O 5 ' FROM TO . DIAMETER [THICKNESS MATERIAL. _
List all applicable well construction penniis(Le.WC Conn%State,Variance,etc.) /
It. S'4.1 ft. ...4"Ziale- I . Th. - , ?rt.'
3.Well Use(check well use): ' - ' . ' - '
Water Supiil 47.SCREEN•y Well: • :
FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
• °Agricultural OMramicipal/Public• ' ft. ft.
OGeothennal(Heating/Cooling Supply) 4teidential Water Supply(single) ft; ft. •1,";.• . . ,
0Industrial/Commercial , . OResiciential'Weer Supply Orred) GROUT. ,
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°Irrigation °Wells>100,0000PD ' FROM . TO MATE.ATAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply WAII ,
• • • KECEVEE)
0Morutonng. . ft.
0 ft' 2. N 04 in -_ fit.v---t
S. ft• a poi-Oen:A 1.7(.4-7,../
Irrjection Well: rr.i (.1 a nli
ft. ft.
• ' 13AquiferRecharge r c- k q' 28•tatoundwater Remediation • •' ' •
19.SAND/GRAVEL PACK of applicable) • '
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0Aquifer StOrage andeocautii prot.7,4aintearrier • FROM TO MATERIAL - . - EIVIPIACEMENT METHOD
°Aquifer Test DWQr•300Stormwater Drainage 3 . ft. 11. i . .
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°Experimental Technology ['Subsidence Control . ft. fe. ,
• OGeotirrmal(Closed Loop) . °Tracer' '20.DRILLING LOG(attach additional sheeb if necessary)
FROM TO , DESCH/710N(eolor,berdent,soilfra etc type,grAle size.eft)
°Geothermal(Heating/Cooling Return) - °Other(explain under#21 Remarlcs)
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- - • 4.Date Well(s)Completed: 2-4 S -Zy 'Well ID# . '
ft. ' .ii. 14'on"' e • PO r•. . . ' *
. , -5a.Well Location: ', - .
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Oar-) 1'791, I -m,L.. ' • - ' - ' ' ftiL_ Dail ;6 PS:11 i
••' 7 , Pacaity/Ownei Name , : Facility ID#(if applicab . . ft. ft. C h al)-1 ct.r GrmA. Ch. go
. - MD -e i,t.v- okx Ch -Aft' • 14-- •-Tn. ft.
. - • Physical Address,.City,and Zip ,'
attt.5 1 ,4.1 . , • .. - . 21.REMARKS/
County • Parcel Mena=Sort No.(PIN) ' ' :g.3Ie ciliq-- 77. '
. . _ 5b.Latitude and longitude in degrseshninutes/seconds or decimal degrees: . ,
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(ifwell Sold,one lit/long is sufficient)
22. • • _ _ • •
.3ti ‘9,g1 55. N Certifi 5 i)i i if 1- 5/ w • .
6.Is(are)the well(s): grIftermanent or °Temporary ' Signature 6:1CcitiPjf±tor '
4 , . Date
>Air . • By signing this fofmI hereby ceri(6.that the well(i)was(Wire)consirtited in accordance with
7.Is this a repair to an existing well: ayes or 0. ISA NCAC 01C.0100 or'SA NCAC 02C.0200 Well Censtructkn Standards and that a copy
!phis is a repair,fill out blown well construction information and explain the nature of the of this record has been provided to the well owner. . •
•repair under ON remarks section or on the back of this form.
23.Site diagram or additional well details: •
You may use the back of this page to provide additional well construction info ,
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Ov,ef in Rdniarks Box).yo,may also attach additional pages if necessary.
drilled:
. 24.SUBMITTAL INSTRUCTIONS • ' .
AO9.Total well depth below land surface: ' C-2.- • (ft)
i• , ,.For multiple wells list all depths((afferent(example-3@200'and 2(g100') Submit this GW-1 within 30 days of well completion per the following:'
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Ifwater level is above casing we
. ,„‘), 24a.•For All Wells: Origins! fomi'to Division of Water Resources (DWR),.'
10.Static water level below top of.scasing: / 0 6 '
v Information Processing Unit,1617 MSc,Raleigh,NC 27699-1617 • '
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11.Borehole diameter Li Y.' .(in.) 24b.For Injection Wells:Copy to k;raWR,Underground Injection Control(IUC). Program 1636 MSC,Raleigh,Nd27699-1636 . • .
• 12.Well construction method: 7?oiari _ a.A.A..•
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the '
. ,(ie.auger,roux cable,direct push.etc.)
county environmental health department of the county where installed •. •
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• FOR WATER SUPPLY WELLS opax: • • • . •• ,
24d.For Water Wells prodricin over 100,000 GPD:Copy to DWR,CCPCLIA
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•13a Yield pm) I Method of tesk. ri . . Permit Program is.1
,1611 c,Raleigh,NC 27699-1611
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13b.Disinfection type: ki i PI Amount: 'i i-- ii.•••
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. :Tenn GW-1 , , .North Carolini Departnient of Davironmentel 9uaiity-Division of Watr.r Resourcel , Ir• • •.a....