GW1--04257_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.�Well
[Contractor Information: Ja.G A(s O YT 14.WATER ZONES
WellContractorN FROM TO DESCRIPTION
fL R. 7
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Rcable
L, m u l/l�S w�( 27/'t'l1/•� 2!f/G ont 7n 8 �o / R T,a SSS MATERIAL L
it rL / in. //
Company Name i 16.INNER CASING OR TUBING eothertrtaI closed-loop)
!2.Well Construction Permit#: o !. 9.3 02 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnrction permits(i.e.UIC,Coun(y,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): fL R. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) ®'Residential Water Supply(single) R, IL fa.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0ft' g R E4 .Te
❑Monitoring ❑Recovery fL (L
Injection Well:
❑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. tL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG lattsch additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,Aarda soluroch io eta
/ y/ fL rc. C 1,"
4.Date Well(s)Completed: I -/Well ID# fL 3 R R& .sL�
5a.Well Location: 11)
ft. R
1 E 1(��1 fY1C'S
Facility/Owner NameT Facility ID#(if applicable) ft. R.
7,7o20 wiCsof) R c4 LA/ fL fL
Physical Address,City,and Zip rL R
met-�1f�e n b Lt I'Q% 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
_3S. 19q N �o . '70 W :
6.Is(are)the well(s): Weanent or ❑Temporary %gnavffv5f250F&ed Well Contractor Date
By signing this form.I hereby certify that the wells)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Wvo ISA 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 remarb section or on the back ojthis 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: Q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lr oo (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple ivells list all depths if different(example-3©200'and 1Q1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,use"+"
11.Borehole diameter: y/ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
/�(in') Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 0 �� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the cotmty, where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producing over 100,000 GPD:Copy to DWR,CCPCUA
C, Q I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ✓ Method of test: I7 7�
13b.Disinfection type: H T/1 Amount: ?el Q 7t-