GW1--05843_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
c_\(‘tA( \ ` 1•A\1, / \mil.\\ J�I r- v S\f\.•``n H.WATER ZONES
Well Contractor Name
OM TO DESCRIPTION
; �`R' Oft'
NC Well11 Contractor/�Certification Number ` 15.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
FROr.L.L. • l0\V S L1 G`\ r c.`\‘Y`-• -1 \M ft y� ft. t X t DIAMETER TO fn. THICKNESS. eI MATERIAL
Company Name V l 7 III
. �^ ` O� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): rt. it. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic it. It in,
OGeothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft ft in.
❑Industal/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TEL MATERIAI. EtVACEMENT_METROD&AMOUNT
it. (t
Non-Water Supply Well:
6 go, ec,,ti ot pa 1).)-rD
❑Monitoring ORecovery ft. ft
Injection Well:
R. R.
❑Aquifer Recharge ❑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 ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rods type,grain size etc.)
p ft �v ft. 0
14 2
4 6 43.s1
4.Date Well(s)Completed:C\•\'a`ti Well ID# 'a 0 ft y,..\ ft. el,
1.r c Wort._
5a Well Location: 4y ft. aUp ft e,vi.c At%
\ii C ')u;\c 16's vt_o .2P0 ft. 3G ft. 1I /I
Facility/Owner Na Facility ID#(if applicable) ft It.
(XCI rFA R\1\e t- M:\\2tS rt. ft
Physical Address.City,and Zip ft ft. '
l \r t to...) v l'\C Ca
- C � 21.REMARKS
County Parcel Identification No.(PIN) 11 '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22• tin:
L!
rV ci:.,.•:.,j .J
3kk•�acN�a\ N -- V�w s��a� W 71I 1 j
6.Is(are)the well(s): Per manent or ❑Temporary to of C 'fled Well Contractor Date
L9
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: [Wes or CIVO 1SA NCAC C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy,
If this is a repair,fill ow 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 GeoprobelDPT 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-I is needed. Indicate TOTAL NUMBER of wells (add'Set Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300
(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®100')
' i/i)1 24a. For All Wells: Original form to Division of Water Resources (DWR),
, 10.Static water level below top of casing: (fti) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-I617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
1 I.Borehole diameter: o I`t (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f.-- .o\- 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) c Method of test: I
T1� Permit Program,1611 MSC,Raleigh,NC 27699-1611
i��13b.Disinfection type: 'k Amount:�k