GW1--05273_Well Construction - GW1_20240906

WELL,CONSTRUCTION RECORD(GW-1) For Internal Use Only. •
I. ell Contractor Information:
'd V1a 1 I - rots • i4.WATERZONES '. -
Well ContraciorName
��Bc
FROM TO p
a 0
" R. ft.
J ft. ft.
NC Well Contractor cation Number
s 15.OUTER CASING(for multi-cased wells)OR LINER a Ilcabtc ..
y� U I l is1�['I i.(� FROM i� ' TOE p D/A/MR THICKESS MATERIAL
+�Jy 1JIt -' 1 > '\,1L, 1LIII f 1 /T/ 7 CJ ft' b t In.
Company Name .z�' UG
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Constructlon Permit#: FROM ' TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.01C,Count, at !Variance,etc,) ft. ft. in,
.. 3.Well Use(check well use): fr. it. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑MunicipaUPublic fr. ft. in.
0 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft :in, •
Dlndustrial/Commercial °Residential Water Supply(shared) 18.GROUT •
❑Irrigation OWells>100,000 GPD • FROM TO 4' r/.
RIAL EMrf,ACEMENTMEThOD&A1rtOUNT
Non-Water Supply Well: O rt.. Z© ft _f A/
VCl'y ft. ft.
❑Monitoring DReco '
Injection Well:
uifer Rechargeft• ft.DA
q OGroundwater Remtxiiation
uifer Storageand Recovery19.SAND/GRAVEL PACK(if applicable)
DA Q °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifbr Test OStormwater Drainage ft• D.
OExperimental Technology °Subsidence Control ft. ft
❑Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets If necessary)
OGeothotmal(Hearing/Cooling Return) °Other(ex�ll fin under#21 Remarks} PROM TO DESCRIPTION(cater,hardness,soil/rock type,grain size,etc.)
( Completed: r 2i�''Zi� a fL `© ft. G/ct
4.Date Wells) Well ID# /0 ft a' C) fr. L 1 , ) S/a,�, . I
5 .Well L cation: r-► i R. S•3 ft. i,► /) r-.//)t cA e Ir�f`f%
LbC'ekeii
acility/OtvnerName '-,�`� ft. ft.
rr __ Facility IN(if
lcs it-1 CSr e mf e kA ft. ft. - --.
Phys' I Addross,GSty.and Zip e� ft. ft, ' ``�``1....L . 'F.f t./
ion CJ- - L 17-O rJ\J 21.REMARKS . . .S E-0' 2024 .
County Parcel Identification No.(PIN)
Ir,fo'T,4i 7ir,rs •4;-g Lira
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: pvecAsQ4
(if well field,one let/long is sufficient) 22.Certification:Syr 9c5n31 N 00 9/5 7,l l W / >J��//
g'`'z2�z
6.Is(are)the well(s):krmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby ce't(datt the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: QYes or Io ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,Jill out!torn well construction Information a!d plain the nature of the of dris record has been provided to the well owner.
repair under t#21 remarks 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 GeoprobelDPT or Closed-Loop Geothermal Wells having the same
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:
/ S 24.SUBMITTAL INSTRUCTIONS
(�7
9.Total well depth below land surface: f/C,
For multiple wells list all depths if dierent(e ample-33@200'and 1Qi0o� ( } Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing: ! ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if-water level is above casing.use 6.-1-;
24b.For Injection Wells: Copy to DWR,Underground Injection Control(I(JC)
11.Borehole diameter: f��1 (in,)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing;over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) /
/ Method of test: ,/i.)t✓ Permit Program,1611 MSC,Raleigh,KC 27699-1611
13b.Disinfection type: r1 rig Amount: /6.414,s