GW1--03451_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well C ntractor Info ation:
/l1 l S ��aay i 14.WATER ZONES
WellContvactorName FROM TO DESCRIPTION
ft.
L13-3" , ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
L.
9• A1 S W`U Oi i..-I FROM TO t DIAME,TER THICKNESS I MATERIAL
Yny 1� T I%. -L�ft. (_ in. ,,Z.$O I P(C
Company Name 16.1NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: -I 1�-1`-1 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County.State,Variance,etc.) 4.r ft. /_4.j ft. i( in. • �Q
3.Well Use(check well use): ft. ICE ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. rt. in.
OGeothermal(Heating/Cooling Supply) LIRRISIaintial Water Supply(single) rL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -IL/ R• .k.) R• ?ti ,� 4,..NL
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. fL
❑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.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soWroek type,grate stu etc.)
ft. ft.
4.Date Well(s)Completed: Si 1'lay Well ID# it ft.
•
5a.Well Location: ft' ft.
LAC f Lk lrlQ l Yhs ft. ft i k C.: V 01 . t�C,I.
Facility/Owne)Name Facility IDN(if applicable) ft. ft.
(*IQ U .1WLua.-a..J 0 0 Gt_Lb0/0
ft. ft.
Physical Address,City,and Zip ft. ft. Ir.tt,,:t,..1,71 •' ''.Z r:4 J rl
S-k r' j 1 Ot 1( 21.REMARKS D,I.(..,i.:A
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long` is sufficient) �p ZU l 22.Ce • ca• `�r/�jL�
3 Cr �7 �'�Y / N O6' 91-)51/1' W �1�7I `1
6.Is(are)the well(s):aanent or ❑Temporary Si of Carded Well Contractor Dace
QPerm
By signing this form,1 hereby certlfv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: pit+e5-or MN() 1 SA NCAC 02C.0100 or I SA 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 W-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: /00 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2(§/00')
` 24a. For MI Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ftt) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"1"
11.Borehole diameter: O (In.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 21S)tax. so;lit_ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) f 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
/4/it Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / ° Method of test: o
_13b.Disinfection type: 1- / // Amount: ?e I n-t N