GW1--03641_Well Construction - GW1_20240618

WELL CONSTRUCTION RECO (GW-1) f For Internal Use Only: •
1.Well Co or.Information:
/2...e..ye-N___L
Qamo Vr`r h re G w 1 •FRO14.WATERM ZONESTO
Well Corttragar DESCRIPTION
35 3 5 d ft �20 ft
ft ft .
NC Well Contractor Certification Number
�-, _ 15.OUTER CASING(for multi-cased wellsLOA LINER if ap liable)
�f'�-/ ! rC.)1-'h -e_,,s FROM ft I TO Lti
Company Name /� ft in•
���{� 6..2.Q/13 7,-r 16.INNER CASING OR TUBING(geothermal dwell-loop)
2.Well Constriction Permit ff; ` FROM TO DUaIETER THICKNESS MATEWAL
LW all applicable well construction permits(ie_(IX,County,Stale,Variance,etc.) 1I-' ft it/d tt,• s r✓ in-, I. �,t
3.Well Use(check well use): g ft. d ;a `t� I
Water Supply Well: 17.SCREEN -
❑Agricultural ❑MtmicipaUPublic FROM TO t'L METLR star sus THICKNISS MATERIAL
ft. ft is
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single)
ft R. fit Industrial/Commercial Residential'Water Supply(shared)
IS.GROUT
❑Irrigation ❑Wells>100,000GPD FROM I TO MA IMP1ACUfErfrMITHODB AMOUNT j
Non-Water Supply Well: • - n R 2� ft e :k I-- ,�^ y P
❑Mcevtoring ❑Recovery :/ ft ft /'�'► r •(
Injection Well: as pGA-i -t
❑Aquifer Recharge n f. l
❑Groundwater Remediation I
❑Aquifer Storage and Recovery OS�w�Barrier 19.SAND/GRAVEL PACE of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft• -
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attatl additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(calor,birdies,raa/rvck type,pain sae,ate)
ft. ft.
•
4.Date Well(s)Completed: 6-1--'2-4- w.f.. ft ii. -
-
Sa.Well Location: ft ft
• T OM M14 . TJJ&s • ft. ft _-
•
• Facility/Ownerll� Name facility ID1(if applicable) ft ftj
TK/D�..1''C csSO p C-n,Q,1 R. � ft. ft Y �
Physical Addra,City,and Zip / 1 ft. ft JUN l $ 2024
ns
W Y w� 1 21.REMARKS/
County / IreL;.7 + ,g:lrir
Parcel Identification No.(PIN)
e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient)
3/ y ,, S O t 22 Certification:
(p N -alp ��d W tho'c�
S:2 - Zv
6.Is(are)the well(s): Permanent or ❑Temporary / 2 36► sig....a . CatiS Well Contractor Date
By signing thu form,I hereby,:entity that the well(s)was(..ere)constructed in accordance with
If7.Is this a repair to an existing well: ❑Yes or myNo 1SANCAC 02C:0100 or'154 MAC 02C.0200 Well Construction Standards and that a copy
this II a repair,fill out known well construction information explain the nature of the of thu record has been prortded to the well owner.
repair under I21 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 Rtrrtaric Box).You may also attach additional pages if necessary.
drilled:
t' v 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: (ft)
For multiple wear list all depths y'different(example 3®.200'and:@l00) Submit this GW-1 within,30 days of well completion
p per the following:
10.Static water level below top of casing: C 6 (ft) 24a. For All Wells: Original form to Division of Water Resources
.(f water level 1r above car/n Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • (DWR),
)�
casing
care�+���
11.Borehole diameter: {in.) 24h.For Injection Wells:Copy to DWR,Underground
Injection Program,1636 MSC,Raleigh,NC 27699-1636•
Control(NC)12.Well construction method: C. {-3-rim( . _ 1 l-
Eta auger,rotary,cable,direct peal;etc.) t 24c.For Water Supply a;nd Open-Loop Geothermal Return Wells:Copy to the
coucty 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 l' Permit Program,1611 MSC,Raleigh,NC 27699-1611
�i t;l
13b.Disinfection type: � 1+ Amount: E. r-+�
Fa OM-1 North Carolina De
partment of Fnviroomental Quality-Di Visi•....,r car_.__o--_.-__