GW1-2023-02245_Well Construction - GW1_20230307

l'
WELL CONSTRUCTION RECORD(GW-1) For Internal Its -e Only:
' 1.Well Contractor Information:
� 't 046 dlPc 14.WATER MONES I
Well Contractor Name ✓ FROM I TO DESCRIPTION
4 C%3,4- Jets ft- e) . "
. • '4
NC Well Contractor Certification Number `90 it I i f i 6 9efk ci r
O�j r� bid
15.OUTER CASING(for multi•eased.wells)PRIMER(tfUp livable) -
�/ ��F Or;11) �h FROM I I TO I DIAMETER I THICKNESS MATERIAL
CompanyName� "��) ft. in. 1
q 16.INI•IER CASING OR TUBING(geothermal dosed-loop)
' 2.Well Construction Permit#: 3 //'/ FROM I TO - DIAMETER THICKNESS MATERIAL
List all applicable well constracrion permits(i.e.U(C.Comm.,State,Variance,etc.) ft I ft. in.
3.Well Use(chest—well—Use): - ft. I ft in
Water Supply Well: I7:SCREENI : -." -
PROM TO: DIAMh.t bit SLOT SIZE THICKNESS MATER
Agricultural °Monicipal/Public ft I it in.
Geothermal(Heating/Cooling Supply) 1esidentiarWater Supply(single) ft I '' ft in.
• Industrial/Commercial °Residential Water Supply(mod) 19 GROUT I -
Irtigation - FROM ITO MATERIAL EMPLACEMENT METHOD&AM
Non-Water Supply Well: /•f ft- P- ft eet•-ltvot gwpel eL s 4"
•
Monitoring °Recovery ft- I ft � .
Injection Well:
' Aquifer Recharge I- 9m g- °GroundwaterRemediation ft. I ft
19.SAND/GRAVEL PAC (if'applicable) ' -
Aquifer Storage and Recovery °Salinity Bather PROM ITO MATERIAL EMPLACEMENT METE=
Aquifer Test °StonnwaterDrainage ft. I ft.
Experimental Technology • °Subsidence Control ft. I ft.
Geothermal(Closed Loop) °Tracer 20.DRILLINGLOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 1i21 Remarks) FROM ITo DESCRIPTION(color.bantams,soil/rack type grain size.
G� 0 ft. RA-
' Q, ft,
4.Date Well(s)Completed: [ -`er�� Well Balt ; ft 'gp ft
, 7)
5a.WelLocation: r / / f rtr t hi kk— --,4tr7ievtn WCl,16 Ir )yet � q5re lyre.'
f ' � :T
t.
"Facility/OwncrNamc FacilitylD#Cfapplicable) - •=z. 'v i:,-,
P/t bid itS j+Y1 ip) 2/ovtv/iI/c PC ft. ft. M n)J
Physical Address,
City,and�+ Zip ft ft. `, t .1 = �l'C J
1� Y6`1'` v./4 r 14"/`47- f� 09S 21.REUTARKS \ ftis,..,i;Y..../nn ;>>--
- City . Far:el IdentifiaationNo.(PIN) i "' } t LT:.
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees: 1
(if well field,pet tutRaog is sufficient) tit.Ceriitica to
•
3(..;3)-330 g N 41.°74 I/3 Li W d. '
6.Is(are)the well(s) ermanent or Temporary SignatmeofC " edWell tractor Date
�� By signing this orm,1 hereby ce t that the well(s)was(were)constructed in arc
7.Is this a repair to an existing well: ()Yes or 1'f o with 15A NC IC 02C.0100 or 15A NC.AC 02C.0200 Well Construction Standards as
If this is a repair,fill out known well construction Information and explain the nature ofthe copy aphis r has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site di at or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details
construction,only I GW-1 is needed_ Indicate TOTAL NUMBER of wells construction dfltails.You may also attach additional pages if necessary.
drilled: SUEMITTATi�INSTRUCTIONS
9.Total well depth below land surface: 1-10 - (it) 24a.For All!Wells: Submit this form within 30 days For multiple wells list all depths ifd�erent(example-3 200'and 2ta 1003 , of completion
construction to the following:
10.Static water level below top of casing: (0 (ft.) Divi I ion of Water Resources,Information Processing Unit,
IJKater level is above casing,use"÷" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1-Boreholediameter: h m,)
24b.For Infection Wells: In addition to sending the form tothe address
.12.Well construction method: /j% I)t4.--7 above,also submit one copy of this form within 30 days of completion
(i.e.auger,rotary,cable,direct push,etc.) / constriction tol[he following
FOR WAI'1✓lt SUPPLY WELLS ONLY: / Division oilWaterResources,Underground Injection Control Progr
)•
[tom i 636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3•I Method of test: /f l l i 1 l 24c.For Water.Supply&Injection Wells: In addition to sending the:
L �j the address(es); above,!also submit one copy of this form within 30
13b.Disinfection type: HI-i f Amount: O O Z. completion of well construction to the county health department of the
where constructed.. ,