GW1--03698_Well Construction - GW1_20240618

WELL CONSTRUCTION RECO (GW-1) For Internal Use Only: -
1.Wel ctor•Informatio
'14.WATER ZONES
Well Co leme FROM TO DHSCRIPTION
14 5 q -7 5 • zo° ft y2) ft
ft ft
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(lisp linable)
cc,h.J )3 ro 5 -e_v s FROM TO
ft ft DIAMETER THICKNESS MATERIAL
in-
Company Name
1
) / 5 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: v lD m
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,eta) ,-i-I ft J�•/ it s; ,), in. ; Y/7 I/J,`, ^vt.
3.Well Use(check well use): ft.
Water Supply Well: ,)7.SCREEN
DA cultural DMu FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
nicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) -
ft ft. in.
❑lndustrial/Commercial Residential Water Supply(shared)
13.GROUT
D Irrigation ❑Wells>100,000 GPD FROM TO EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - /j g 2 3 ft ,1 AA, . . ..A
❑Monitoring ❑Recovery G•/ ft ft. j(�
Injection Well: ��r1 s I� A
• ❑A Aquifer ft.. ft.
9 Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery 0 SalBarrier 19.SAND/GRAVEL PACICQapplicable)
FROM TO MATERIAL EMPIACEMENTMSIHOD
DAquiferTest ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
•
• OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necwary)
0 Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCtIPTIQN(nix,hardness,aaStr.ek type,gr,e size,etc)
ft ft
r
4.Date Well(s)Completed: 5 30-�- Well ID# ft ft tV
`,,, L
ell Location:s l ft. ft. JUN R 2024
I (d( 1 cCI 1 C S r er ) ft. ft
3if um.
• Fac=Owner lame Facility IDM(if linable) ft •ft iirib wi P r'1 'a' Aa:
uref na1Ls/ /7ft -
ft.-
" fift r" "�
Physical city,and Zip ft
11//// < I,., �� 21.REMAItXS/
County l Y Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell Sold,one lat/long is sufficient) 22.Certif
seAlibic,
36.f .),L) " N P ay, .) 5 • tiV gteL'' -
ata
6. areG '` 3 /Is(are)the well(s):YPermanent or OTemporary 2 / ,( Signature of ed�Vep Co�rtrscwr D
JC_�U
\\// By signing this form,I hereby c urtfy that the wells)war(were)constructed in accordance with
7.Is this a repair to au existing well: ❑Yes or YJNo ISAM'AC 02C:0I00 or'ISA.VCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill out,6town well consnaction information explain the nature of the of this record has been provided to the well owner.
repair under 121 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 some 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:
ZD 24.SUBMITTAL INSTRUCTIONS
Total well depth below land surface: (ft)
For mu/np/e wells list all depths ifdierent(example-3@200'and 2®100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (( a (ft-)
24a. For All Wells: Original form to Division of Water Resources (DWR) .If water
6`/
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: ` _(in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(RTC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well constructio m n me push,
CS { a-Y _
(i.e.auger,rotary, ctio d me ru,etc.) t A. r 24c.For Water Supply and 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
• //�� •13a.Yield(gpm) Method of test /�}i 1' Permit Program,1611 MSC,Raleigh,NC 27699-1611
I�- 013b.Disinfection type: r 1' 'A Amount:
Form OW-1 North Carolina Deautrnent of Environmental Quality-Division of Water,Reawurces
R.,....a<t ten.e