GW1--06170_Well Construction - GW1_20241014

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:�
�O6-)Y
Well Contrac Name FROM TO , DESCRIPTION.
y (0 _A ft.
R, rt.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased:Wells OR LINER f op licable
I Y �O{`/li M t u/l+ 1�, +Q /► ill/t . FROM : TO DIAMETER THICKNESS M ERIAL
1 1 1 1 V\f/s�Wei\` C V'Y�V �V� • U ft. 9A ft. ./g to. Mr...;4 tr
Company Na F 1 / t�I/1a I)
(�� /� �D ✓ J /� 16.INNER CASING OR TODING.(geothermal closed-loop) 2 ;:;;::_:'::':;:;•:i?,
2.Well Construction Permit#: 11 w O( �t7(,. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits O.e.UIC,Caton);State,Variance,etc.) It. R. In.
-
3.Well Use(check well use): ft. ft. In.
Water Supply Well:
pp y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑� Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) letesidential Water Supply(single) ft. It. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) ;
18:GROUT"�::ri.:::a:::::..-......,::.:-:::7:.::::::;1{:?•:�::::::�::..:i''';`.`.::;:;:: ii:: :za5;z:iS`i[i:Y'r.':`:inc`:;;:;:a:::: 3
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; 0ft. ao ft. lx{(.I.k pair( (
❑Monitoring ORecovcry It. R.
Injection Well: -
ft. R. I
❑Aquifer Recharge ❑Groundwater Remediation
.19:SAND/GRAVEL PACK(if applicable)';: ;:'.r::: •::-:,:.::::.::::(iii:;'. t:aa;t %::,:E::;:rl::f.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT MLI HOD
❑Aquifer Test ❑StormwaterDrainage ft. R.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20:DRILLING LOG(attach'additional uheeta'ifiieccsaary).:::[:;; oata '':::i:Ca::�,' '
FROM TO DESCRIPTION(color,hardness,soIFrock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
5'O ft..4.Date Wells)Completed: 1.-34t11 Well ID# [{ 0 ftft. ,06. lft. tecktuot
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5a.Well Location: , �� �1 ft, l7� rt. yyY(4� 4�'
rV'Y_�.j tt. rt. V�
Facilrity/O r Nnme [� ���j� Facility ID#(if applicable) tl % ,,;K,'1,T 11 j) 4
V • `1 1 ti ti-[/+ 41e in R. ft. ,„
Physical Address,City,and Zi
ft, ft. OCT 1 4 2024
:21::REMARK3
`AI CC A it ,.:rm._:z7 f C. a;, f, Irv?:
County Parcel Identification No.(PIN) t41I,fr ., t v I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iff well field,one lat/long is sufficient) L` 22,Certification:
. L4�t;a N 7y0• i'F7 1 1 W
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing litisfonrt,I hereby certl&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No 1S4 NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this to a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well otmen
repair under#21 remarks section or on the back of this farm.
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
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9.Total well depth below land surface: 1 W 5 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if-different(example-3 a(�l 0'and 2Q100)
10.Static water level below top of casing: j ,,``V t 24a. For AU 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"+"&p
11.Borehole diameter: u r!4 (in.) 24b,For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
�tit-12.Well construction method: 1 " r 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) 4�a Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: _ Amount: Li ' 3G Ti `
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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