GW1--05302_Well Construction - GW1_20240906

WELL CONSTRUCUON RECORD(GW-1)
For Internal Use Only:
1,Well Contractor Information: I
rLe'°i r'11 ' "i f, d4.V is TO.C.A4• tieN 14.WATER ZONES •
Well Contracr Name FROM TO DESCRIPTION
� $� � 145 '� 1�ft
NC Well Contactor Certification Number R. IL
4
t� �� i1 ` 15.OUTER CASING(for multi-cased wells)OR LINER(If ap llcable) -
FROM f THICKNESS om S C.W@\k 1JC'`1{ 41 I ��h I �sil DIAMETER
It / �� � ntaTeRwL
Company Name 111C
r��s 16.INNER CASING OR TUBING(geothermal closed-loop)2.Well Construction Permit#: :J l SI-S 5 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construtton permits(i.e.UIC,Counrv,State,Variance,etc.) R. ft. In.
3.Well Use(check well use): 2 ft. ill.
Water Supply Well: 17.SCREEN
❑Agricultural -FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑MunicipaVPublic n. ft. In.
❑Geothermal(Heating/Cooling Supply) &Residential Water Supply(single)
ft. ft. in.
Dlndustrial/Commercial ❑Residential Water Supply(shared)
❑lrrigauon It GROUT
❑Wells>100,000GPD • FROM TO MATERIAL • EMPLACEMENT toD&AMotiNr
Non-Water Supply Well: 6 R 'Z.b ft C,
❑Monitoring ❑Recovery � � PCI.s�
R
Injection Well:
DAquifer Recharge ❑Groundwater Remediation ft. It.
DAquifer Storage and Recovery ❑Salinity Barrier 19,SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stonnwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(ifeatinglCoolin Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,aomrock type,grain sit etc.)
R. ft.
O Ib r cieLy
4.Date Well(s)Completed: 1 1 Zy Well ID# i 0 it x O It L
E7r'-mod,, G.Ia.f
Sa.Well Location: .t 24) n' 100 n' b 1 vG 9' .r i -c
PAtarNetcA% nu./me.t!rl Locust- fL ft. J
Facility/Owner Name Facility ID#(if applicable) R- ft.
__Lc:1 -c0 -Co114i A-_we asy It ft. _ ;, f
Physical Address,City,and Zip rt. ft. - _L'L_: �! t���
64-A+l l/ 14"1014,1 21.REMARKS }a 0 b 10Z4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Info;t s.i e n r �+sa. ,� U>
(if well field,one IaVJong is sufficient) 22.Certification; Q/2O0
3S.2( b39 N B0.39C12k w
9Yeee...'.„if I Izi./z4
6.Is(are)the well(s): &Permanent or ❑Temporary Signature of Certified e I Contractor Date
By signing this form.(hereby certlfv that the wells)ovs(were)comrtrucied in accordance with
7.Is this a repair to an existing well: °Yes or ?No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill ottt knorwr well construction Information and explain the nature of the of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (n.)
For multiple wells list all depths ifdifjerent(example-3®200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
f 24a. For All Wells: Original
10.Static water level below top of casing: form to Division of Water Resources (DWR),
((water level Is above casing,use"+ (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ( )
11.Borehole diameter: (in.) 24b.For Inicction Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A- 20\r"s/ 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: A 24d.For Water Wells producing over 300,000 CPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 , Method of test: `((.. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: [" 1 L I-4 Amount: 1 �Ilfx4