GW1--05826_Well Construction - GW1_20241001

♦•L.1J1. N./V1Ill11\V'Le 11V11 xWt,vltV tVvr-11 rorinternal use Only:
1.Wellll�Contractor Information:
/�i/'lkJt L /iii.... iC 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
� • MO ft. 2 u A ft.
c -r�/3 ft. /GJv ft.
NC Well Contractor Certificatio Number / 15.OUTER CASING(for multi cased wells)OR LINER(dap Ikable)
de. �Jf kid/ 4,,,,,,‘ FR� ' TO DIAMETER THICKNESS :MACompany Name IA/ ft. 73 ft. in. .ZSO /A� C
16.INNER CASING OR TUBING(geothermal closed-loop)
2- /2.Well Construction Permit#: ZL / q 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.
F Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) s idential Water Supply(single) g, ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPWEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft.
t .
OMonitoring ❑RecoveZ�l ft ��t>�C K�
tY ft. ft.
Injection Well:
ft. ft.
0 Aquifer Recharge OGroundwater 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 ft. ft. -
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets Ifnecessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(eater,hardness aowroek type,Srain size etc.)
o fL /y
ft. y
4.Date Well(s)Completedc3 11 Well ID# /y ft. 30 ft. h G
5a.Well Location: -i 30 n' r R- I� c �Cl/'-i LON'll y3 ft. 0 ft. // is/Facility/Owne✓,r NNNfaa/_me AFacility ID#(if applicable) It. ft.
/�4.-5 dt..t �///-�i. ft. ft.
Physical Address,CRY'''.and Zip It. ft.
1.4,1o•-• OB 1d50a3G 21.REMARKS
County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35•0 v 8 77 N ga. ' 3 //L W ..4 9, Q 3_,41-1
6.Is are the Signature of Certified Well Contracto Date
) well(
s):(s:) rmanent or ❑Temporary
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 ?Igo /SA 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
�/
9.Total well depth below land surface: 7 0 0 (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3©200'0'and 2@100')
(ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �j
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-I 617
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: / 14.,‘ 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) Method of test: "A/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
��13b.Disinfection type: A Amount: 2,4II