GW1--05210_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor- n
Information:
l -hri!i / I V` i I i S/ I0.--, bII. 14,WATER ZONES
Well Contractor Name ( A\.r� ! FROM TO DESCRIPTION
ft.
ao3q �M � ��' ft. �� rt.NC Well Contractor Certification Number
15.OUTER Ca-51.
(for multi-cased wells)OR LINER(If ap licable)
�,L /1'1iA Ii�S Wf-I I ,fir;I I; �L FROM ' To It
DIAMETER`m' BUG � MATERIAL
�
Company Name /7G
t�/1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: .'&19 I 0 0 - FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.UIG County,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): it- ft. in. -I
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TIHCKNESS MATERIAL
❑Agricultural ❑pl unicipal/Public ft. it, in.
❑Geothermal(Heating/Cooling Supply) 19Residential Water Supply(single) R. ft. 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. 1 0 ft. Bahr^ 4 no Ur 1
❑Monitoring ❑Recovery ft.
`rt✓ ft. 1 1 (J
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 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 J TO DESCRIPTION(coax,boniness wrUrock rya grain size.etc)
( 0 ft. /a ft. red,
c/a/
4.Date Well(s)Completed: '1 5 Y't Well ID# fO fL 35'ft•ft. p U i (cal
Vv�
Sa.Well Location: 3.� ft.. bT e.1�� , /�- f A t. ip /
Grrlc1Qv,a� CQ�D 6y ft. /bonft y raili?f�- I►* esfon�
Facility/Owner Name �r �{� hFacility►D#(if applicable)
P a0 Address,3 cirri.an " 5 W I� '`fi R. ft.
M-• G,lW 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude anf longitude' degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is suffi Tent) 22.Certification:
35. 11°33 N g0.0111) W .. /12e/Z1 /�z y
6.Is(are)the well(s): Ia•Permanent or OTemporary Signature of Certified Well ContractDate
__�// 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 ItP o 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#21 remark 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.construction,on1yoGW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: // / 24.SUBMITTAL INSTRUCTIONS
CO
9.Total well depth below land surface: O (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths rfdiJjerent(example-3®200'and 2®100')
..5 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
/I
11.Borehole diameter: t/ /g (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f�f r2Rol-A- . 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:Copyto
Q ^ Permit Program, DWR,CCPCUA
13a.Yield(gpm) v v�/ ,c/Method of test: /4 I�/� 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /4 7/i Amount: 3 /'ice,S