_Well Construction - GW1_20230320 (2)

WELL CONSTRUCTION RECO ...... (GW-1) For Internal Use Only:
• 1.Well Contractor.Information:
•
..• 2004.fivitervco,.
'14.
Well Co r e FROMWATER TOZONES
DESCRIPTION
• 3535 • (OO fG' abaft
ft ft.
NC Wellerti5eation N er 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) •
/. n_ FROMft. TOft DIAMETER THICKNESS MATERIAL
Company Name ,
/ Q 16,INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#: d/S9O&7 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(I.e.WC County,State,Variance,etc.) .-i., f6 j O ft;' �C f`' in. Mir h... n J
3.Well Use(check well use): ft to ft.
•
41.SCREEN Water Supply Well: •
• ❑A cultural FROM • TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) 4Residential Water Supply(single) t ft. .
❑IndustrialCommercial DResidential'Water Supply(shared)
•
18.GROUT
❑Irrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ' v ft. 23 ft. Next r M i'Y'4 rr
• OMonitoring ❑Recovery ft ft.
• Injection Well: VOr'•1')Ctz:.( P f ,Y A
•
•
❑A ulferRechaz a •
it. fh ` I
9 g 0GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.S�/GRTO L PACK(ifif applicable)pp •
EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ' ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft..
• DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,Brain sae,etc.)
fc ft.
4.Date Wells)Completed: 3.-q- Z 3 Well ID# • ft Y't;
5a.Well Location: ft. ft. ' `lam�-r -�^
Zen .f l ern j'h, ft. A /� e n
• Facility/Owner Name Facility ID#(if applicable ft tt r��IiD '�� �)?�
2 h 1,1 m Y-o c 1 lam( I S 2 •
T.tt ft •
Ift;;=Lm.:„❑ .-y.7/;.,j :r•A
Physical Address,City,and Zip ft
/, ft.
Ct d t�;)-1 ,21.REMARKS/
Co Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
3 / l ' 1 .5 !` 2 22.Certification:
• N t�V � J� � ( I `,it
.6.Is(are)the well(s): rmanent• or ❑Ten ores /� / Signaturepl.
Well 3 `/3- 3
p ry r V cp Contractor Date
B
signing this
7.Is this a repair to an existing well: ❑Yes or ,it I •
SA NCAC 02C�:0100 or7S4.W C 02C.0200 rm,agreby cer0 that the (W Well Construction Standards and twas(were)constructed in hat a opy
If this is a repair,fill out/mown well construction information and�rplain 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 faint.
23.Site diagram or additional well details: '
S.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 Rtniarlrs Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS `
9.Total well depth below land surface: 2 2'0 gt.) •
For multiple wells list all depths tfd(fferent(example-3Qa 200'and 2p100') • Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing: S b • (IL) 24a. For All Wells: Original form to Division of Water Resources
If water level is above cosing,;use 'i ;� Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617 • (DWR),11.Borehole diameter: t .(in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
•
12.Well construction method: 'R DialAte'
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-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(gpnr) t-r ()' Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
' t,,1
13b.Disinfection type: k T I Amount: Cl Grr . -
7d •
Form GW-] .. ,- .. •_