GW1--05275_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
•
/F I✓)r, h/ k 1,-,..-. %C 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
7�3 6 R. ft.
NC Well Contractor Certification� Number /J////► 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
. !„ AL!!/L /
, r'}l e 1 l , r J/l/n ' FROM � /T/O� DIAMETER THICKNESS MATERIAL
Company Name 1//Z 7 I ft. 671 in. •Z5 /VC
/j 16.INNER CASING OR TUBING(geothermal closed-loop)
f
2.Well Construction Permit#: . � • 6/ FROM TO DIAMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft n- in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft it. in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO M§TERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. R- . /(4.0s/l'C /-
❑Monitoring ❑Recovery ft. ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test• ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.Hardness soWrock type Grain size etc./
7-Z-`7l 0 /4 n. Y�lM) CI
4.Date Well(s)Completed: Z• Well ID# /5 rt 3g It ��r, rr SIa.TZ
5a.Well Location: :.`‘ 3.5 ' 01 n' 'kit-- $'/0 G
Facility/Owner Name o /� (�J Facilityo�ID#(if applicable) R' R' ; ;
C K ,Kr d• D� 0 ' ft ft .''L.. . v I._
Physical Address.City,and Zip kJ ft ft 5 E V 0 6 2024
/�,I/ 21.REMARKS
(��r11/O� -/4/7-o//� lii/tsn.r.ce'1 0• ,-.-S/LC.',�vAA
County Parcel Identification No.(PIN) Dl�rCA3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, let/long
giis sufficient) 22.Certification:
34/ /086- 7i N 00, - �I..00 w ' 'Z,7-0 /�LJ
6.Is(are)the well(s): fRirermanent or ❑Temporary Signature of citified Well n 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 (Nei 1SA 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
QVT
9.Total well depth below land surface: Da (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 l200'and 2®100')
' L 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3S (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
limiter level is above casing,use"+"
11.Borehole diameter: 6/0 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
1 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: . �G/� 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 WELLSONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) le 5 T// Method of test: 'Ai
. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /'`7J/7/ Amount: / >a�s