GW1--00286_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i e LI t'''N '4g)\\t— GC"V i(1 ../4.(.. t-SOr> 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
'2,©3 2.t;tit ft.
NC Well Contractor Certification Number Ct• -Leo It. ���
D(�� � r i 15.OUTER CASING(for multi-eased wells)OR LINER(if ap livable)
\c. \e,\1 br,,`\y r. FROSt i TO n[ARs''ER THICKNESS MATERIAL,
Company Name 11 ��lYv// \ ,�1 ft. f„4 1 ft I b( (�in• i I,Z `'�
2.Well Construction Permit#: c,14 R-NA)�-'2 023 FROM
CASING TO OR TUBING(geothermal closed-loop) V
List all applicable well construction pertnits(i.e.UIC,County.State,Variance,etc.)3ft. DIAMETER THICKNESS MATERIAL
ft. in.
3.Well Use(cheek well use): ft. ft —in
Water Supply Well: 17.SCREEN
OAglictlltnral FROM TO DIAMETER�SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft, • ft. in.
❑Geothermal(Heating/Cooling Supply) 4Residential Water Supply(single)
❑ ❑
Industrial/Commerciain• R. In.—
Residential Water Supply(shared) ,_
❑lerigation 13•GROUT
❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it• 2-C: ft
❑Monitoring ❑Recovery ter— ���+'��
Injection Well: ft. ir.
DAquifer Recharge ❑Groundwater Remediation ft. ft
❑Aquifer Storage and Recovery ❑Salinity Barrier 19•SAND/GRAVEL PACK(if-applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Stormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control
ft. ft.
°Geothermal(Closed Loop) °Trlc 20.DRILLING LOG(attach additionalacets if necessary)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness.son/rock
type,grain stet,etc)
4.Date Well(s)Completed: O f Zq 123 Well ID# /D ft- r O rt. h�0,%°�.Jr, Gi��
1 •4-�
5j .t.
aa. ,Well Location: ,�•
•
'.A ft. ft.
C/1,c� ower ►)4r r�tr•t / I ('� ft. ft.
Facility/Owner Name Facility ID/i(if applicable) ft. ft.
s "
Physical Address,City,and Zip ft ft. - e �•
cabct�-�S 21.REMARKS. 2024
Ufa
County Parcel Identification No.(PIN) thifa�i.:1�i f�r% �
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) —
�y 2 22.Certification:
N `cabtyb601 W
�.eit l e 4 2 /2
6.Is(are)the weli(s): Lermanent or ❑Temporary Signature of Certified Well ontractor Date ,
By s
this form,I hereby
gning
7.Is this a repair to an existing well: :Yes or No 1 AtNCAC 02C.0100 or 15A NC Crttfi102C10200 Well Consr ction S andardsat the well(s)was(were)cotructed inaand thance
at a copywith
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 t121 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
(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:
zi Da/ 24.SUBMITTAL INSTRUCTIONS
0.Total well depth below land surface: (It)
Poe multiple.cells list all depths ifdifferent(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing 3 D ' 24a. For Al] Wells: Original form to Division of Water Resources (DWR),
(jivater level is above casing,use'+" O Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter; fIR (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control((UC)
�, Program, 1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: "k--c.
(i.e,auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Lot 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(gpm) 3 Method of test: i r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1 ` Amount: t \h'ST