GW1--05194_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •
oef r 01 t% ad k / 1,-,...... Ace, 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Z.-103 7� rt. 3/0 rt.
0 ft' ft.
NC Well Contactor Certification Number
�z /ti, !JS &,/e,ll(l
tit//4 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licabte)
FROM TO D[AMErER THICKNESS At
RIAL
Company Name V rr L/1,€, f ft. 6 2 ft. /5Iry in.
(� D / Z.So
p�/� 16.INNER CASING OR TURING((geothermal closed-loop)
2.Well Construction Permit#: ( /4- tile- 6. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consnitction permits(i.e.CRC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): D. ft. In.
Water Supply Well: 17.SCREEN `
❑A cultural M FROM TO DIAMETER SLOT ME THICKNESS MATERIAL
❑�� uunicipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) I3Kesidential Water Supply(single)
ft. ft. hr.
❑lndustriaUCommercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL E CECMEN METHOD&AMOUNT
Non-Water Supply Well: O ft. ft. //
❑Monitoring ❑Recovc �� "'�ft�7" Gu✓
n R ft
Injection Well: _
❑A uifer Recllar a ft. ft.
q g ❑GroundwaterRemediation
19.SAND/GRAVEL PACK(if ad cable)
❑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) OTracer 20.DRILLING LOG(attach add Clonal sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solVrack type grain size.etc.)
o ft. o( 7 ft. lax 1
4.Date Well(s)Completed:9 -Z5.- i Well ID# , ft, / 5 it. f
Sa.Well Location: ` 6 3 ft- 70 R. 1 ( r
Imbl�.$nca6 Arelk+�6..w/.e s' 76 ft. you ft. ij to n i f"
te,
Facility/Ownerlty Name�� Facility ID#(if applicable) ft. ft.
Z DZO 4,[ (GL/o ,4J g. ft ft
r
'Physical Address,d City,and Zip ft. ft.
Cc,/JGt!)---6(S 21.REMARKS
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.Certification:
34-1766/6 N '0, //o/q W 7�� ��ri�✓�
v.-.z,5-7 L/
6.Is(are)the well(s): llmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fares,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or II1,1Vo ISA NCAC 02C.0100 or 1SA NCAG 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 tie well owner.
repair wider#21 reinarla section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 17/00
For multiple wells list all depths if different(example-3@200'and 2@I00') (ft.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6�� (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /i1rk
(i.e.auger,rotary,cable,direct push,etc.) 0 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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 27699-161 1
13a.Yield
(gpm) //:) ) Method of test: /'/ ✓
13b.Disinfection type: , /t"// Amount: 7,,,.)✓7�.5