GW1--05848_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1,Well ontracto Info 1fliJL
1 5 14.WATER ZONES
11 C c i FROM��` TO `�J(A��,' DESCRIPTION
anIt
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ell Contractor 'fication N( ber 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
K tir'S v) 1I` FROM TO DIAMFT THICKNESS MATERIAL
1 tt ft. 6 iw
Company Name a �V i t_� ,
16.IlYIYER CASIiKG OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: ...74. Oro FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County.State,Variance,etc.) ft. ft. in.
t 3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic n. ft. in.
❑Geothermal(Heating/Cooling Supply) .residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FRO TO TERIAL LL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: ft. ft. ( nf&j 1G.. r-r
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft.
❑Aquifer Recharge OGroundwater Remediation ft.
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) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,bardtailtr«k type min sire etc.)
ft. QC) ft. it\r1c
la)3 1
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4.Date Well(s)CompletedC a 4 Well ID# it. ft It 4
Sa.W LocatioCati.t. 21. it. vocic. r 51Q-E
yvic*A.
Facility/Owner Na Facili ID#(if applicab7cjs
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4Lii'7VG, (.It ft. ft. _
Phiysical Address.City,and Zip ft. ft '` ••.
Y 1 � �%Z 21.REMARKS ,
i 1 ���111 J o/'\� 4! } t j7+
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
3elcfiel nelat/b�no,issluffficiieent) /� /,�[ 22.Certification:
l 1 ((LAY N V t 601tl/ / '1 W
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature offied We Co r Date
XBy signing this form,I hereby certify that the wells)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or o iSA 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:
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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-I 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: 3,1 5 (n-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2(§100')
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10.Static water level below top of casing: - ''.•((JJ44����)) ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
((water level is above casing,use..+6 Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
n b� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ,(fil 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 N LLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: (f� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 'Tl Amount: I"1