GW1--05246_Well Construction - GW1_20240903

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1.Well Contractor�on Information:
•
T'F/ c Lrc/yet-/L/
C_L/r3 ��c crf,On 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor game ft. ft. -/`0 Sd
L/(ao a , ft. ft. LJ
NC Well Contractor/y� Certification Number 4� 15.OUTER CASING(for multi-cased wells)OR LINER(if a Ikable)
FRO
Company Nam,/Gt//i S we l/ L1a�/l�/.n$ L/'C. /�t ft. 5
C� f4 DIAMETER
, 23,in. THICKNESS/02 S MATERIAL
�C.
�/e
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �. _ - a 0? J ..'OK7OSg FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) rt. R. in.
3.Well Use(cheek well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) girrsidential Water Supply(single) ft. R, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: t7 it , O f LJ�e'1•1�ri
❑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 It. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it rt. q� /
sic"
/� d a� /�tocr /7
4.Date Well(s)Completed: (1 '/� -1 Well ID# ,2 0 ft i(0 ft t pin
5a.We 1 Location: :j, O it `j g rt' t!tc.e __S-
Jpr�ni a�i' L c Gu54 58 it. ,5 ee- Z? 6 tea;
Facility/Owner Name Facility MN(if app'cable) ft. It.
/a.S_S Set.l�i vct n ii i!is L.,JV
MI ." ft. ft.
Physical Address,City,and Zip ft ft f r / ;
C _ /_ rr�5 21.REMARKS
County J 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:
.3S• 1-16a2 !! N So , W 4-5I3 W 8- Pi -al/
6.is(are)the well(s): er manent or OTemporary a Ce Well Contractor Date
By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or tSrgr ISA NCAC 02C.0100 or ISA 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: O 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C 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 1®100')
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing.use"+" (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-I 617
11.Borehole diameter: f) 7$' (in.) 24b.For Injection Wells: Copy to DWR,Underground injection Control(IUC)
/� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /l O 71-G_1 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
13a.Yield(gpm) Method of test: j �' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 14 7 Amount: i h S