GW1--05192_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:_ /
SeFFte`/ �4 C/ e r- .vi n V cec/CSon 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractoronntct/ Na ['
'7 (ooa ft. it. ft o - /3J / eo
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Ilcable)
V] /, M6t.ill's
/i s we(/
ef / V r,1 it1 FROM TO DIAMETER THICKNESS MATERIAL
Company Name ! (/ t. / ft. Li 8 ft.
CO Pe in. 0 J.s Pv e.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: a.,a, -. a // FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
1
3.Well Use(check well use): it ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mu/nicipaVPublic it. R, in.
❑Geothermal(Heating/Cooling Supply) (]Residential Water Supply(single) ft. rt. In,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a D ft, i9-0 �.t / d�C.t/L��/
❑Monitoring ❑Recovery R. ft. f�
Injection Well:
uifer Rechargeft.
❑A q ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test' ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,eta)
Q �,/ 0 ft. 01 ft. ;��o wn h e l/
4.Date Well(s)Completed:.) -7-,2-! Well ID# ca 0 ft. 0g ft. 7, / q 5"
5a.Well Location: :•� zi O It. d,t� . �J C4 e S( .
K \ I it ft.
FacilityiOwner
^
littyiOwne�r Name Facility ID#(if applicable) ft. It.
/'`! 2 )00R'e CI in; f/�;Y1 cL ft. it
Physical ddress,City, Zip it h•21.REMARKS ', `
County Parcel Identification No.(PIN) I ' .,.LL , '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
3S. aso 75 N goo '11 '7 J i -5 w .�
6.Is(are)the well(s): GM"rnanent or ❑Temporary f ed We I Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I111‘ ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#2l 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 Remarks Box).You may also attach additional pages if necessary.
drilled: v 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C2 d 0 (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2®100')
10.Static water level below of casing 3 S (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level isa above casing.use top
11.Borehole diameter: h /r' (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /f O r C/ -- 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
m ^� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Ot v Method of test: 4, ✓•
13b.Disinfection type: bit 7171 Amount: 3 la,'M1 7 j