GW1--00239_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: •
1.Well Contractor Infforrmati
i...e V.,-k BGi it... G c, ) i J c...ic- -.t i'-, 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION4�J ,tuft. 3 Oft.
^
ft. L-� to ft.
NC Well Contractor Certification Number �� I
'D'Di-.
{{{���� l p 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
� y�v\l%S L y y_e, \ b,r-`+1 �i,,�`, FROM ' TO DIA.MEER THICKNESS MATERIAL
Company Name `` `N ` `\ i +1 ft. ft, b j p� in. I : �?. ?' S C
16.INNER CASING OR TUBING(geothermal closed-loop) �Y
2.Well Construction Permit#: Z ?-2:1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. rt. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. ft. in.
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft, ft. in.
-
OIndustrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL " EMPLACEMENT METHOP&AMOUNT
Non-Water Supply Well: V 7q ft- 2c:, ft. ii. i)G �4
t y:--
❑Monitoring ❑Recovery ft. ft.
Injection Well: ._
ft. ft.
❑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) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Gardness,soil/rocktype grain size,etc.)
`
tL rt.
Well(s)Completed:la'ZS 2 � /� `�xY,� �'�4.Date
Well ID# /© ft. 4/0 ft. 4� .s a s i G." I i i'S' c>I
5a.Well Location: :•„ z/0 ft. Li2 eft. btue. ,5 k4..
ft. ft. ` _.,.
Facility/tYivner Name t Facility ID#(if applicable) ft. ft. :i * V L�
ieli S , ft. ft
' ncr,L iVd\ Q�-e- p ty i 2U14
Physical Address,City,and Zip ft. ft
OCND vrN oq 03Li_
c zto 21.REMARKS ttAu
,.^ti.•'4'Ufa‘
County Parcel Identification No.(PIN) iW.fC�n('I1j1r4i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
?,, 40,H b N C.V= fl/� •
W ,6�./1'7 1 F "/:/G>� - / -25'Z�
6.Is(are)the well(s): •Permanent or ❑Temporary Signature of Certified Welt Contractor Date
By signing this form,I hereby cert(that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *No 15A 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-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
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 tt 100')
L/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: / Pt) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use'-'
11.Borehole diameter: i/� _ (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: eit\r" r"y 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: t 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Ip0k+c'
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 20 Method of test:
13b.Disinfection type: i TVA Amount: r'l