_Well Construction - GW1_20230315 (49)

WELL CONSTRUCTION R]ECO (GW-1) For Internal Use Only:
' 1.Well Co tractonInfgrmation:
14.WATER ZONES
ame 2 FROM TO DESCRIPTION
Well ConhactorN 5 �00
3 ft' uj tt
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf a lieable
FROM TO DLIMETER THICXMS MATERIAL
ft ft in
Company Name
16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: /L (/V FROM I To I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(Le.Mr-Como,,State,Variance,e(c.) -t. it ' ft 7 Y
3.Well Use(check well use): ft ft. in.
Water Supply Well: 7.SCREEN
FROM I TO I DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft in-
❑Geothemnal(Heating/Cooling Supply) esidential Water Supply(single) fc ft in.'
❑IndustriaUCommercial Residential'Water Supply(shared) Is.GROUT
olrrigatlop ❑Wells>100,000 GPD FROM TO MATERIAL WaLACEMENTMEMOD&AMOUNT
Non-Water Supply Well: Q ft Z ft N M r Y= -f tc
❑Monitoring ❑Recovery ft fb
Injection Well:
ft ft,❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If a lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft tt
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soitimek type,grain sae,etr
ft ft
4.Date Well(s)Completed: 2' 27 r Well ID# ft A
5a.Well fLocation: ^� tt ft
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft ft
�,5h;rla Crttw Ay r— LU; Ow- - tt
Physical AddreQ City,and Zip it
21.REMARKS,(
County , Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laNlong is sufficient) ) 22.Certification'
el
L/ b 1S �f/
s N n -' 3 ,W
.6.Is(are)the well(s):X-Permanent or ❑Temporary L�30 J Signatur' e ' d'•well Contractor Date
By signing this form,I hereby cerrifY that the well(J)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1SANCAC 02c:01oo or'2sANCAC 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 thisform.
23.Site diagrTm 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: '' IITu
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft
For multiple wells list all depths if different(example-3@200'and 2000') ( ) Submit this GW-1 within 30 days of well completion per the following:
�
10.Static water level below top of casing: 1 d ft 24a• For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing " ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ,(in•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Weil construction method:(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Sunnly and Oven-Loop Geothermal Return Wells:Copy to the
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) Method of test: CC_a/�� Permit Program,1611 MSC,Raleigh,NC 27699-1611 i r
13b.Disinfection type: Amount:- .1 2 ��