GW1--02535_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informaton: •
kf..l ilik, AeiAa io lam, /AG.-% li ce- 14.'WATER-ZONES.'>
Well Contractor Name FROM TO DESCRIPTION
fyy)ft. ft.
36 ft:l ft.
NC Well Contractor Certification Number ) n - 15.%OUTER-CAS
ING'(for multi-ctised.welts),OR LINER-(if ap"livable)`
Z , ��fk/4 j L- C .// 6/?' / FROMM TTOO / DIAMETER THICKNESS/ 7141
/ Wt// OJ !/ 1�
Company Name fr e
+� p� .16:INNER.CASING-ORTUB1NGi(geothei inat'closed.loop)-`- ;. '. -
2.Well Construction Permit#: L/3 —Z !3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perinits(i.e.UIG County.State,Variance,etc.) ft. ft. in.
3.Well Use(cheek well use): ft. rt. in.
- Water Supply Well: 17.'SCREEN :.
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic it. R in.
0 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. -
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD •
"18:GROUT•:'.: ...:...... . .........•,.: ::._ ..-.,:.:; ::._:::: .;..:.:.:.. ; . :.. - ...
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: e5 ft. ?S ft. ben7c5
0
1-te pAe{ re ct
❑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.
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG'(attach additional sheets if necessary):.r".- --:-. .. . -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soi/rock type grain size.etc)
•
2 i7 rt. 5 ft. ca
4.Date Well(s)Completed: 3'Z 1'Z-7 Well ID# . ft 50 ft 7' r :1'1601 e_
�: 74 t,r:7,-'•; ,.�T,„ '7 ft. /44c ft `l td S Kit �i
Sa.Well location: :�� � «-» ® L
��ev/ __
/ 7 6,,^ '' . , ,- *% .0! f• spa ft. 1 l r
Facility/Owner Na life Facility lD#(ifa plicable)-•� ' ft. ft.
60 lo Goue ,4//1/ ft. ft. , ..
Physical Address,City,and Zip ft. ft. ' 1-. . ,i. I' .?•--rd'-jt
,/ 2L-REMARKS,- . .' : .-.• -. .r.''. c--- .-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • "
(if well field,one llat/lonnggiQsufficient) /� 22.Certification: ['"t'dE.+J�
.0i![/// [" N .Vf_�r C/4/o �o /• W •
,
� ' 3-2/-2 9"
6.Is(are)the well(s):,ipPermanent or ❑Temporary Signature of Certified Well ontmctor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or )No 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 rentarlr 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-I is needed. 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 surface: Z' X ) (It) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100')
t 1 Static top of casing: lJ- (ft') 24a. For All Wells: Original form to Division of Water Resources (DWR),
If 10.Swattatic wateris above levelca belowing.us ' ' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6/ (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: !'o 44411 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 6 county environmental health department of the county where installed
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
•
13a.Yield(gpm) Method of test: /71)" Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /2 Amount: */)11- S
.