GW1--05295_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contracto/r I ormation: •
itef
it 1/:✓t if
l- Ir .G-., je./C.<., 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
W36 yd ft. 3zoft.
ft. ft.
NC Well Contractor Certification Number a /) 15.OUTER CASING(for multi-cased wells)OR LINER
(if ap lIcable)
/
a G� . IOU Ai �e-1 i a, 14,1 FROM DIAMETER V MA MAL
Company Name T t. TO
ft in. t Cj
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: • Z3 -/3 9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County.State,Variance,etc.) it. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mun'cipalPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EBf£esidential Water Supply(single) ft ft. In.
0 Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMP MENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 7r, !�ft, . Sr
❑Monitoring ❑Recovery ft. G� ft.
Injection Well:
ft. ft.
❑Aquifer Recha
rge ❑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 ❑Subsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal FROM TO r DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a ft.
/S R.
Alc/cty
4.Date Well(s)Completed: 1-/ --Zy Well ID# /S ft 9// ft 0 di , ��
Sa.Well Location: � 414/ ft. 7i�0 ft. �[y�Fi4/fC
- 55� ,Ile'✓ ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft. ) -� -L. . r'
6e-442/ #11tD ZA. C`�i) ce ft. ft �•t •�L L..
Pltysical Address,City,and Zip ft- ft. S E P 0 6 2024
an,art 060%303 8' A 21.REMARKS INO,,-„i,(y rr.
County Parcel Identification No.(PiN) rl^�o 2 tint
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
.S0Y/3OZ- N o. 70g Z 6. W fCerti �.
6.Is(are)the well(s): rmanent or ❑Temporary
Signature ofied Well Contractor f-30--ZV
( 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 QIYo iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this/s 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 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: � 24.SUBMITTAL INSTRUCTIONS
!/9.Total well depth below land surface: 00 (t) 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 2®100')
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"+"
24b.For Infection Wells: Copy to DWR,Underground injection Control(IUC)
11.Borehole diameter: �$ (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /C t7 ezetz5 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) o 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) . 3 // Method of test: 21Y)/ L Permit Program,1611 MSC,Raleigh,NC 27699-1611
#13b.Disinfection type: 1/ Amount: J/1'„T i