GW1--04259_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well o tractor Info tlon:
I 1-S Q ✓ 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
NC Well Contractor
Certification Number '^` 15.OUTER CASING for multi-cased webs OR LINER If a Ilcable
( 1 ,/f 1, Jt. ` �_(� 1 j�l FRO f TO DIAMETER THICKNESS HATE
aLJ 1r rv`v` / `�iv\ vv ft ft in.
Company Name !� 16.INNER CASING OR TUBING otherroal closed-loop)
2.Well Construction Permit#: U� L4 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) R• R. 91 in.
3.Well Use(check well use): ft. rL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R, in.
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GRO_ T1'
❑1ni ation ❑Wells>100,000 GPD FROM TO RI E.MPLA ENT METHOD&AMOUNT
Non-Water Supply Well: O ft•
❑Monitoring ❑Recovery % ft.
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 R, IL
❑Experimental Technology ❑Subsidence Control ft. T
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Heating/CoolingFROM Return) ❑Other(explain under#21 Remarks) ft. TO R DESCRIPTION(color hardy solltrock ain size,etc
4.Date Well(s)Completed: lV a 4ll ID# M R.
5a.Well�CLo
cation: (� R. (L
( I I � C 'J ft. n
Facility/Owner Name I t 1 Facility,ID#(ifapplicable) fL ft.
xa I�i So,C�Cat -P 11cx S{ L 1' ft. %
Physical Add re s,City,and Zip ft. tt. t
r •t t �LA.- /„ u ( 21.REMARKS -
b
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.Cerdficatio
N W
6.Is(are)the well(s): vermanent or ❑Te rary Signature° nnactor Date
By signing this form,I hereby certifv that the well(s)ans(were)constructed in accordance with
7.Is this a repair to an existing well: es or It 15A NCAC 02C.0100 or 15A NCAC 02C.0100 well Construction Standards and that a copy
If this is a repair,fill out known well construction formation 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 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 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 ivells list all depths if different(example-3Q200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 00 Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
lfivater level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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 costa e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: