GW1--05844_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W t Contractor Information:` I + 1 C
friill u I I I J III 11 U�1AS1 1i n/N� 14.WATER ZONES
Weil Contractor Name J \ FROM TO DESCRIPTION
t�o,3a A IIIJJJ ft. ft. 0 �'7D
R. ft. I
Well Contractorr� Certification Number c)ri 15.OUTER CASING(for malts-cased wells)OR LAVER(i1 ap usable)
. L• I , lu I('�J 1��� I a I (nnc,. FROM TO ' DIAMETER ' THICKNESS MATERIAL.
QQ It. U ft. � 'j� /
Company Name J /(� 1 �!l$ in, e d l) YV l..
• Q/ r- I g H 16.`INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: y I 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): ft, IL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ icipal/Public ft. R, in.
OGeothermal(Heating/Cooling Supply) BResidential Water Supply(single) R, g, In.
0 Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL E 1��OD do AMOUNT
Non-Water Supply Well: 0 ft. 'LO It. 4 ;4r
❑Monitoring ❑Recovery ft. . ft.
Injection Well: R ,
❑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 0 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 CRIPTION(color,hardness,soil/rock type,grin size,etc.)
Oft. O R. own `
4.Date Well(s)Completed: ell ID# a 0 fL -0 R. b ) �I�r''"[ 41
5a.Well Locatlo : ,t CLOC
ft.
L R. ` 1 ur 1 t
11Colb KmineDu 4, ,. C ft lei ,. •11[l�r
Facility/Owner Name Facili ID#(if applicable) ft. R. 'j�A/K�
SDa T)tk4 w a t 1hr)1, -Ci ,W1 nm , ft. ft.
Physical
Address,City,and Zip �[ r ft. ft.
u11 1171n V'I-I LIV-W a 21.REMARKS
County Parcel Identification No.(PIN) t .. ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latliong is sufficient) 22. e ' cation:
34. aeAS N CC).5%I W 1 - I I-aaaLl
6.is(are)the well(s): LBPermanent or OTemporary
Signatu of C�Well Contractor Date
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 IStio 1 5A 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: � 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 1.)0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iifdifferent(example-3(Qa 200'and 2Q100')
10.Static water level below top of casing: Y 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" C' O (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I _ 1 I �r 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �i J 11 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well ction method: (�bt 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger, Lary, ble,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin;over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) C Method of test: zA 1 r Permit Program,1611 MSC,Raleigh,NC 27699-1611
I 11 13b.Disinfection type: t-I Amount: `, pi n4-5