GW1--05478_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
6orre),14 PCMitt�reil+ 14.WATER ZONES
Well Contractor Name IJ FROM TO DESCRIPTION
C151154 ft. ft. 1
ft. ft.
!
NC/Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
atoll s Well rind PompCo . FROM _ TO DIAMETER THICKNESS MATERIAL
Compan)�Name 0 ft. 58 fit. 6./25 rn (sI/w tV G
�^/ 16.INNER CASING OR TUBING(geothermal closed-loop)
V y EL r1
2.Well Construction Permit#: g0 o,Li 00 '3 / 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. ft. in.
Water Supply Well: 17:'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERW,
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ft. ft. in.
❑IndustriallCommercial DResidential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO M TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. t0 t It, /d lra-S
:Monitoring - - DRecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 1 EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) (y fit (J
58 fc ��CI
1"G1a� r
4.Date Well(s)Completed:OVO/Zq Well ID# 5 C( It. 605 fit. Nt-11
// ft. ft. -a f,,,,, --} �,,,,
5a.Well Locations:/ '27 .-,i' 4.i l"'"t a
i2 al d / CCt r ft. fit. SEP 1- 3
Facility/Owner Name Facility ID#(if applicable) ft it 2024
/ /' fit. ft. rt 74 fir
q �l1;e, Sell 214. G--o f 7 lrl0:a.�:c e�. r. t u+
Physical Address,City,and Zip ft. ft. 1�i4►t..a.Ll
21.,REMARKS
a nu,mile_
County 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:
35. CPI T70 N -$2-Scni f w
o a'z y
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contra or Date
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ("No ISA NCAC 02C.0100 or 15A 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 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: COS (ft.) 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@I00') !
24a. For All Wells: Original foam to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617IMSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.)
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: FO.'t..r 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) 2 Method of test: A-i ir" Permit Program,1611 MSC,Raleigh,1NC 27699-1611
13b.Disinfection type:al lt7Yi le , Amount: Gc� S
1 '
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018