GW1--03668_Well Construction - GW1_20240618

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WELL CO RUCTION RE O (GW-1) For Internal Use Only: ,
1.Well Contras
0.
7,fa,
. 14.WATER ZONES
Well Contractor N FROM TO DESCRIPTION
"b G ft. GZD ft
� s � -7ft ft. .
NC Well Contractor Certification Number
15.OUTER CASING(for sauld-cased wells)OR LINER(if ap Gable)
J rU til -e_V PROM TO ft ft DIAMETER THICKNESS MATERIAL _
Company Name
is
2.Well Construction Permit#: L.1/ 01 2 16.INNER CASING OR T iBING(geothermal dosed-loop)
FROM TO nIAMErLR THICKNESS MATERIAL,
List all applicable well contraction permits(I.e.UIG County,State, Variance,eta) --I-J ft t/q ft. (7/1 m. nice
_ -e`,` rn YID
-I �J9 Ylt
3.Well Use(check well use): ft ft. in.
Water Supply Well: V.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL, ❑Agricultural ❑Mtaucipal/Public • ft ft is
OGeothermal(Heating/Cooling Supply) /residential Water Supply(single)
ft ft in. -
❑lndustrial/Commercial ❑Residential'Water Supply(shared)
18.GROUT
❑Irrigation OWells>100,000 GPD FROM TO MATKt1AL EMFLACHtZPr OD&AMOUNT_,
Non-Water Supply Well: • 0 ft �5 ft _Net / A,t, t 1J
• ❑Monitoring ❑Recovery V ft ft. vC ! /v\ j
• Injection Well: ��Q> � r p.t/
❑A uiferft ft r
q Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery 11 SAND/GRAVEL PACKS applicable)
�' OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage fc ft
❑Experimental Technology ❑Subsidence Control It. ft.
• ❑Geothermal(Closed Loop) • ❑Tracer 20.DRILLING LOG(attars additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIQN(cobs,h adaesr>H7heck type,grantetc)
ft ft �
4.Date Well(s)Completed: 6'5-4q Well ID# • ft 11. 1J� n.r' (Era, b )
5a. ell Location: It. ft
41,eL- CI I4 r r A. ft ft -
Fact7ity/Owner Name Facility ID%(if applicable) ft ft L+
f'Cf i ) ' C2sil& Gr4 R .- ---ft.
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fL - JUN x .S ZOZ4 .
Physical Juices City.and Zip ft. ft
IIV�►"\Aa ,`Jrx•6.►• �-"�lint
Gu 3 a 21.REMARKS/ t
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one lat/long is sufficient) 22.Certific
3tP' i 1,' ),t' N S I / •7)5' 52- ' e-.
6.Ts(are)the well(s):VPermanent or ❑Temporary 30 Xb i Signature Of ;Yell Connctor Dam
ay
//// By signing this form,I hereby uu7f y that the wells)war(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ayNo 15A NCAC 02C:0100 or'ISA NC4C 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well conluctlon information explain the nature of the of Mu record has been provided to the well owner.
•repair under/21 remarks section or on the back of this form.
23.Site diagram or additimai well details:
You may use the back of this page to provide additional well constrrction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the slime
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rerzari. Box).You may also attach additional pages ifrurectary.
drilled:
&A/\t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lJ (ft)
ifdlyferent(example-3(a 200'and 2@100� Submit this GW-1 within.30 days of well completion per the followiDg:
For multiple wells list all depths
10.Static water level below top of casing: 0 (ff) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ij water level is above caring,use--11" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: 6! {in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a +a-rirt . _ r
(i.e.•ages,rotary,cable,direct push,etc.) l 1 24c.For Water Supply anal Open-Loop Geothermal Return Wells:Copy to the
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
m Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield
(gP ) Method of test Air ,,
13b.Disinfection type: I ( l) Amouut: g q (1---.
Fora OW-1 North Carolina Department of Envirowneutal Quality-Division of Water Resources
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