GW1--02590_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:�i
A..CiIllt+!l 1.5ef(�- T/Y/a,.. Irice,.
14:=WATER-ZONES.''
Well Contractor Name FROM TOGG . DESCRIPTION
/ .. 35aft•, '-?.RC)IL
0 j ( ' ft.' ft.
•
NC Well Contractor Certification Number
/A/ l I //�� 1 .15..OUTER CASING(for multi-cased tvells)'ORLINER('crap licablc)=:•:.'.•• '
6- Ma [/5 / )e'lI Ai I!i (FROM TO j DIAMETER THICKNESS MATERIAL
r W T I�Zft. 1/'I ft. 6Y? in. 50� 2/1 i l/�
Company Name L1 I .r 16.:INNERCASING OR-TUBING:(geotherinal closed=loop):- . - -
2.Well Construction:Permit#: 1 i /'I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) ft. ft. in.
., 3.Well Use(check well use): ft. -ft. in.
Water Supply Well: 17.SGREEN '
FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) )&Iesidential Water Supply(single) It. ft. in, -
❑Industrial/Commercial ❑Residential Water Supply(shared) _
❑Imgation - ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:" iJ ft. �G' ft. b. 1,?/t . z,U!re
❑Monitoring ❑Recovery f. • rt. I
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. ft.
OGeothermal(Closed Loop) OTracer •,20:DRILLING`LOG"(attach:additionahsheetS if necessary):.' '. • -`FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.eta)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
r C) f. /e ft c.l� J
4.Date Well(s)Completed: a L1 Well ID# /p ft. ,'3 5'It. 17 d /cv 07— 119 1� C.4
5a.Well Location: .;o �S ft. 1//;ft• , /1 - i-� Gl Ulf t/� .
A� �/ / :.► 7 r J
1/l�4v- - IC it,-T/S //y ft. 0Q ft. 5r-Ci/1 ile-
Facility/Q vner Name Facility ID#(if applicable) IL T ft
4/C/C I e.cct/'r 4.,a2 Id.
ft. ft.
${tysical Address,City,and Zip (� ft. ft. .l e E ` I1 r i" ;..
Gas-aM APR 2 G ?.0�4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L,:,..:-.=t,:•`, :"': ..a.-,..,;;,, i•;,•;;11
(if well field,one Int/long is sufficient) 22.Certification: (3:u'C;ti°-.0C
,1 -.4_,,,„„),da,____...._
,R_Jci
6,Is(are)the well(s):Afffiermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,Ihereby certf that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15A 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 remaria 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: 7@20 (ft) Submit this GW-1 within 30 days of well completion per the following:
if
For multiple wells list all depths different(example-3@200'and 2@100)
/ 24a. For All Wells: Original form to Division of Water Resources-(DWR),
° 10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+•'
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6. I/a �J (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: .`,i 1►' ,a�/�1' / 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /0 Method of test: /'/ i
13b.Disinfection type: // -1/1 Amount: i A