GW1--00241_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contritetpr Information:
F
Ve\j WI e t kc (&CflY\ `4 a c Ic..,saPN 14.WATER ZONES
Welt Contractor Name FROM TO DESCRIPTION .
'� b'-Aelt Ill off, ft.
NC Well Contractor Certification Number �gDfL ft.
n� c , 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
,b .„,. J`\\C We k ` t 1�i\`Ne\s FROM TO 1 ft DIAM TER THICKNESS MATERIAL
Company Name lv 41 ft ILi'J I (l1�i in. , t �� � P`IC
16.INNER CASING OR TUBING.(geothermal closed-loop)2.Well Construction Permit#: ' -6 - -2- C7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(La,UIC,County.Slate,Variance,etc.) ft ft. in,
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
❑Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft n, in,
OGeothermal(Heating/Cooling Supply) 41Ifftesidential Water Supply(single)
❑Industrial/Commercial in.
❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD . MOM TO MATERIAL ' EMPLACEMEINTZIOD&AMOUNT
Non-Water Supply Well:❑Monitoring ❑Recove G ft. `2.ch f- 13enonhle poor
Injection Well: rY ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation ft. it
°Aquifer Storage and Recovery r
❑Salinity Barrier .SAND/GRAL PACK(If applicable) -
19FROM TOVE MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remains) PROM TO DESCRIPTION(color,hardness,sowrocktvpe.groin size.etc.)
D ft, i D rt
t--Y-1t• it 5..I(>•• j
4.Date Well(s)Completed: (Z- )2, 23 Well ID# /0 ft .20 it.
5a.Well Location: ..; .Z� ft. 500 ft. b .e k4
Ka-VA-- n e S ft. ft. ri�
Facility/Owner Name Facility ID#(if applicable) ft. It.
Ligi . `- ; t 1
AMP©bola - ft. ft
Physical Addres�City,and Zip
ft. ft. ( ,
0 \�� t�g�-2,3 '_e)Sq Zi.RE113ARICS. t) �}"-
County Parcel Identification No.(PIN) ,W,:r,r-_:-• ;,
in d 1,/,,,e:; ,- ;
56.Latitude and longitude
degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
JS'a 12eV1 N q30, St-1S-1 .3 W a r
/
? 121'ZZ, � 3
6.Is(are)the well(s): f4A'ermanent or OTemporary Signature of Certified Well C attar or Date
By signing Otis form,I hereby cert(fe that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Wes or ONo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
!filth 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 renrar•kr section or on she 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells
drilled:
i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (>a ( )
For multiple wells list nil depths ifd different(example-3Q200'and 2®100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: '' j Q 1 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use•'T'i (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
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: ‘r A.4-'y 24c,For Water Supply
(i.e.auger,rotary,cable,direct push,etc.) county environmental health epartmentpof the county wl hererinstallied Copy to the
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) B Method of test: lit. t, Permit Program,1611 MSC,Raleigh,NC 27699-1611
r
13b.Disinfection type: T Amount: `Q1 I\