GW1--05899_Well Construction - GW1_20241001

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
\ left rey '�4CA1 pr a,t.c. 17 Tctc/fSoI7 14.WATER ZONES
Well Contractor Na a FROM TO DESCRIPTION
116 0(2 - �o a Core � 59 18S
NC Well Contractor Certification Number 6 0
15.OUTER CASING(for multi-cased wells)OR LINER(If ap Iteable)
I-• %nit.«{"S lt/ea Vrc�11 i n27 =/f/L FROM TO DIAMETER THICKNESS MATERIAL
Company Name a/ / ('6) to /4 in. •
02_5 /-A/C-
.
2.Well Construction Permit#: 0 a3 et 015 D
INNER
CASING OR TUBING(geothermal do loop)
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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural °MunicipaVPublic ft. ft, in.
❑Geothermal(Heating/Cooling Supply) filkfirsidential 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: D ft. a9 . 23,41 1.-42. 1 �
❑Monitoring ❑Recovery ft. cv Rft. /i
Injection Well: it. 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 ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,bardness soil/rock type,grain size,etc.)
q - D a '� Red (:j
4.Date Well(s)Completed: ! -IX Weli ID# eQ 0 it. SO
ft. Wei
a�L a
5a. ell Location: ,.i 50 it. /,0 It ��[Gw2 6,,,ww7`- C,
whi�-�t-c $G L o ft. 3 0o n a c r
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6 01'7 -45r ere l 29R, ft. ft.
Physical Address,City,and Zip ft. ft.
it , ,
Ca6cker , 21.REMARKS
County Parcel Identification No.(PIN) I t h'. .. -r`-
Pi?, . .1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 . 33417o N Rv . ti. yIa w
_ q-ao aY
6.Is(are)the well(s): @immanent or ❑Temporary i ed 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 Quo 1SA 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: et 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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')
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use/"+"
11.Borehole diameter ra �fS (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RD.TL11 __. ry 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) /
I Q t
Method of test: 171 r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: f-{ 7fi4 Amount: 3 io Y1 7l