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HomeMy WebLinkAboutGW1--02557_Well Construction - GW1_20240426 WELL D+ L CONST`'UCTION RECORD(GW-1) For Internal Use Only: ' 1.Well Contractor Information: �j ��/el rl 4&/4- / /✓f/os-'^ Price, 14.:WATER ZONES Well Contractor Name e `FROM TO DESCRIPTION , 3a • / �%ft., / ft. zOS ft. ft. • NC Well Contractor Certification Number 15..OUTER CASING for multi-cased wells`OR LINER(if a licable .DZ ilia iit ,„11 a ll�N ( ). FROM TO DIAMETER TtitCKNESS MATERIAL Company Name ) +45 /171t. ( /g' i. ,z� Pi/c- /' ..16:INNER•CASING:OR.TUBING:(peothetinal.elosed-loop) 2.Well Construction'Permit#: `1 If -00 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft, in. , 3.Well Use(check well use): ft. ft. in. Water Supply Well: _ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft ft. in. ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in. • 0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ❑Irrigation ❑Wells>100,000GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 04 ft. ZO ft kJ/Ian/Ye /ip, ❑Monitoring ❑Recovery ft. ft. Injection Well: ft ft. ❑Aquifer Recharge s ❑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. ft. OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) i _. _. ,'- ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sorl/rnck type,grain size.etc.) a O ft. /g' ft. Gl i y . 4.Date Well(s)Completed:3-Li'Zq Well ID# /e ft / 5 r. brokVil 5l q±C.i Sa.Well Location: q• v- : 145t. �D it. Fo I IO�n It. R. Facility/Owner�Na)mee v j Facility ID#(if applicable)ape)�;� ft ft. z"/,`•Yq7 / yi if../ILC. /U�,/G ide-- i/`!V 5100 I 10( ft ft. I 11 Physical Address,City,and Zip - - ft. ft. t ti-• .5¢arl/ FS,9 21.-REMARKS. ----:'. • . . . A pp ,` i %iO4 .• County Parcel Identification No.(PIN) ,, fIt,:f..-'✓:;...-.':. Jfr/L 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4J ."`t (if well field,one let/long is sufficient) 22.Certification: 35.3y4/7�/ N rD,, Z3cZ3 w Si .3 - zg-'z„L1 6.Is(are)the well(s): Irmanent or ❑Temporary Signature of Certified Well Contractor Date By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or t l o I SA NCAC 02C.0100 or 111 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 remarks 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-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: Z- t2 (ft) For multiple wells list all depths ifdii different(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following: t �� 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: Vt') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" 11.Borehole diameter: ��� (in.) 24b.For Injection Wells: Copy:to DWR,Underground Injection Control(IUC) J Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: 4111 Ao /A'11/ 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA (gpm) / Method of test: / Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield mi 1 13b.Disinfection type: / ��I Amount: �,Jy�