GW1--02537_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • \f/
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1.Well Contractor Information:
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GrliA•� cAkti i I
14.WATER ZONES :-
Well Contractor Name FROM TO
TrOO r�s� DESCRIPTION
C1 o1N ft. C 1�lJ t
ft.• �!1 ft.v
•
NC�Well
�Contractor Certification Number ) 1 15..OUTER CASING(for multi-eased wells)OR LINER(if ap 11cable). -
�I nukui5
�kI�fI 1i7t FROMfLTO ft DIAM,ETER in• THICKNESS g MA RIAL
Company Name / 16 l ( ///�����' Il a�J ''I 2 13 (pill I /a5 1/C�
�y �� ^�� 16:INNER.CASING OR TUBING'.(geothermal closed-loop)- .- •.' . • .
2.Well Construction Perm •it#: FROM TO DIAMETER THICIGNESS MATERIAL
List all applicable wall construction permits(i.e.UIC,County,Stale,Variance,etc.) ft. ft. 1 in.
Y 3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN = -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. It. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) lII:GROUT
❑Irrigation ❑Wells>100,000 GPD • FROM TO 1 TERIAL EMPLACEMENT METHOD AMOU
Non-Water Supply Well: 0 ft.
g ) ft, (.,__• T NT
f)Cx.ii. re.
❑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 ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) OTracer 20:DRILLING LOG(attach-additional sheets if necessary) • .
FROM TO D RIPTION(color,hardness soIVroch e,grain size.eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. fr. ,r f
4.Date Well(s)Completed: 3 4 Well ID# I Oft' 45 rt. �J►/l(L/� 9,r.
5n.Well Location: i,. 0 ft' v//Yo ft. 6 --" ,
C C fL It.
utility/Owner Name Facility!Dll(if applicable) ft. B' - -
r J g �a tX V ft. ft t% ..'qei....i.`61t 1..,
Physical Address,City,and Zip- . l fA ft. APR 2 11 I1�4
ol_iqq''(1 a h 21.REMARICS: . - - '
County Parcel Identification No.(PIN) ' ') Ul,ti.
D':c C-.,2iU^J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well one taat/lonng,is sufficient) Q r r Q 22.Ce ti cation: j, •
3. j {3 I lU 9 N () i a_—!1 U W �'t (� `t�
6.Is(are)the well(s): OPermanent or ❑Temporary Si atura f Corti ed Well Contractor Date
By signing this form,1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orANo 15A NCAC 02C.0100 or 15,1 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair Jill out 47fon11 well construction informationrplain the nature of the of this record has been provided to the well owuler:
repair under P2I remarks section or on die back of this form. 23.Site diagram or additional well details:
B.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-1 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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t@200'and 2©100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: r ao (ft') .Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.us
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11.Borehole diameter: 1 L (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
c.
Program,1636 MSC,Raleigh,NC 27699-1636
Y12.Well c i'•• etion method: y" 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.aug•,rotary,c-,te,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
13a.Yield(gpm) Method of test: c Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: C 1 Amount:—4 Tti '