GW1--05842_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: \
. m•\\\S /�`\1 y v 9..%.,,J� 1144 CATER ZONES
Well Contractor Name DESCRIPTION
�•O'sS �,3Drt. S IL
ft. rt.
NC Well Contractor Certification Number
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_ ` \ ` 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
P).1..... �(\• �..t\\�S .1 w G-``1 `TJ c`\\,.1` -_,13 L FROM TO DIAMETER THICKNESS MATERIAL
Company Name
\.. ft. ul3 ft. �.0 1�i in. S
a. U
r., ''\\ a 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: , of`A-- \ p Lc. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, In.
❑Geothermal(Heating/Cooling Supply) lldential Water Supply(single) ft, ft, in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. P' o ft. N r?0,,
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test, ❑Stormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal FROM06 IL TO DESCRIPTION(color,hardness,soli/rock type,grain size.etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a Q ft, f a C1
vtleNj
4.Date Well(s)Completed:a_11-' " Nell ID# a b ft. 3 O ft. ''r t)+•S'{�1 S1,pl kc
9a.Well Location: :•y 3J ft. y3 fL \JC C
V.1 C DU.rI_citts4 AilerM -
_it a�s0 JS�a{C
Facility/OwnerN FacilityID# a applicable) ft. IL
^ (ifpP )
�\24,-
] \ \•er \ i\; `\ \\CJi t ff si0J�� �'C. ft, ft. ,
Physical Address,City,mnd Zip ft. ft. F
O+r\.\ ll`•-) iy -\O r . ()\C 21.REMARKS
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.Certif a n:
3� C'\'Z�A(ss f1C
- \ N ^ %O - S \ W a
-_Yd_
6.Is(are)the well(s): Ett ermanent or ❑Temporary Si tore of bed Well Contractor to
By signing th 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 SKr- 15A NCAC 02C.0100 or 1SA 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: a�V (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2(100')
10.Static water level below top of casing: yQ (it') 24a. For All Wells: Original form to Division of Water Resources (DWR),
•
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
11.Borehole diameter: La II. (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
n \ \ Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ) a\-(A•r4) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 1 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: ( -.C\-• Permit Program,1611 MSC,Raleigh,NC 27699-1611
'\‘-‘,13b.Disinfection type: W Amount: \ ,p•+-�lr-