GW1--04994_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
G!M r Pa et 14.,Wjptl'-13R'ZZONES
Well Contractor
/N�n e L5 FROM ft. TO �• DESCRIPTION�� ft. ft.
NC We1I Contractor Certification Number
umber/{�/�11 /{�., T 15 OUI ER CASING(foil uilltt-a/s's�e/d�weUs)UR1;TDR))R(if 6p llcwiile)�J/
. 4/` (/(/C/I 1 / !/'. L� .1.�s•Z�i: FROM ATERIAL
ft. TO/ ft. DIAMETER/2 in. 6 THICKNESS
M/V V
Company Nam �/771 �pt
2 //y�� .16:INNER,CASINGORTtffiING1(Peothermal:closed*loop)
2.Well Construction Permit#: a `��~ �V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN+
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEM E(}N_T METHOD&AMOUNT
Non-Water Supply Well: Q ft. �Z it b C 611 Cj?;- p 0 t..ree! /..t_f),915
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑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 fa ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING'LOG(attach additional sheetsif necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. J 7 q ft.
4.Date Well(s)Completer): f)-01 S / Well ID# )‘2/� it. QS-rt G� rGLnlre
ft. ft.
LJ
5a.Well Location:
t
ft. ft i i 7g Min, 1,//5 LA-B r,-(wit-iv/ea)
.
lity/Owner Name FMr
ID#(if applicable) ft. it'
^� p t111t .� � )i '1
cork Le'reK — l ' I o s.5 Id w ft. ft.
Physical Address,City,and Zip ft. ft.
h(�0 a e I I 21,REMARKS .,_-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat//long is sufficient) �J 22.Certification::� `/ 7 L/
"1, S`7 `1 N g I,gSD 77 W ' GL`�[.11 S-"I -oC-.
6.Is(are)the well(s): WPermanent or OTemporary Signature of Cgrtified Well Contractor Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or bNo 15A NCAC 02C.0100 or 15A 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 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 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-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
24a. For AB Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: at) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'!
11.Borehole diameter: 4� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
/ (in.)
-{� Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Y1 O L Q—r y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) / 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 6.--' Method of test: A) if
f
13b.Disinfection type: () I) r/Y1 - Amount: Gu/S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018