GW1--04258_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: /.,
7�-cc�fwr / va a1'r1 �4C�)'SO�I 14.WATER ZONES
Well Contractor Na4 FROM TO DESCRIPTION
ft. rt. sr /D D / 1 190
I (� 0 ft. R.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER s LLeable
w�/�n FROM TO DIAMETER THICKNESS MATERIAL
[.rJ e�� �/`r J- 1/�C / ft fo O ft �O �in. S P!/
Company Name
2.Well Construction Perot#: 0 �l t7r.(0 0 FROM
INNER CASING OR TUBING eotbermai cl THICKNESS
FROM TO DIAMETER 7HICKNFSS MATERIAL
List all applicable well constnrction permits(i.e.UIC,County.State,Variance,etc.) ft. R. In.
t 3.Well Use(check well use): ft. rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MM�u•nicipaVPublic fL ft. in.
OGeothermal(Heating/Cooling Supply) 114Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. a 'L
❑Monitoring ❑Recovery fL rL
Infection 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 R B•
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,bards sowrock in Sim eta
0 f4 a v
4.Date Wetl(s)Completed: A(:;,' $ ell ID# fL h q/�j'aul F.rt cc S
Sa.W�jlLocatio n [ f 0�� tCJ�c +T4
fL R.
Facility/Owen ame ,f Facility ID#(if applicable) n• ft.qS i'g O gr e F R`` fL fL
Physical Address,City,and Zip ft. ft.
fn ecll e e r) 6 I 1:3 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) q 22.Certification:
.35a /-? l l N 80, � 0 � o � W
6.Is(are)the well(s): rfgermanent or []Temporary 14fiaWN06f C&fied Well Contractor Date
_ By signing thisform,I hereby certijv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &<0�+ 15A 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 wider#21 rentar k section or on the back of this form.
23.5ite diagram or additional well details:
8.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I rrW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: CJ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@1001
• ? �• 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: �J�-J (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter 6 1 _(in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
D 1 Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /? 1"4,r L/ 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 county where insta e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
6 Method of test r Permit Program,1611 MSC,Raleigh,NC 27699-161 l
13a.Yield(gpm)13b.Disinfection type: H 711
Amount:. e;Yl.-1 S