GW1--00246_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
•T /' l corer/4&/ n { tI14.WATER ZONES
� PROM TO DESCRIPTION
Well Contractor Mateo rt. ft'
C 40, 6�/ q o
•I(00 t� ft. ft. l
NC Well Contractor Certification Number 15.OUTER CASING'(for multi-cased wells)OR LINER(If ap licable)
Gyp FROM TO DIAMETER THICKNESS MATERIAL
L., rnkli, c Well !/T/Cll ��' �yC- �j, ! ft. Lyf ft.
4 to e/ S Pee.
Company Name /� /' �' 16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: " /Q I 4,D a FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft. In.
❑Geothermal(Heating/Cobling Supply) residential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation °Wells>100,000 GPD FROM TO eMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft a 0 ft. 0 2 St pu m/0 ea/
❑Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK of applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Storniwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,solwrock type,grain she,eta)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) it. /Q ft
e!'ila Lv (..ty
4.Date Well(s)Completed:/0 o�0" ell BM 0 f! 19 ft L4.tt, -5 Z4-Z2
5a. Location: t00 ft- Lug G`�"`e"
Facility/Owner Name Facility ID#(if applicable) y •. �•?-- ..
L13oo Renee Ford ' fd ft. BAN°:.,... I.� +.
Physical Address.City,and Zip J o 2g24
i 511a`„ 21:REMARKS_
County Parcel Identification No.(PIN) Di/v',;.yam, '2 Cti:.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) 22.Certification:
35, l '7S31 N 80 . 416l0a '7 W , , /o -a -�3
/� of C ed Well Contractor Date
6.Is(are)the well(s): fidPermanent or ❑Temporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or itt o 1SA NCAC 02C.0100 or 1SA 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 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Cloied-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1/G.W-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi,different(example-3Q200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: S (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(WC)
Gyp Program,1636 MSC,Raleigh,NC 27699-1636
2 12.Well construction method: O*tar 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
;1 i Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: t l r ,(
13b.Disinfection type: {'f 7/T Amount: I)) /, S