GW1--00948_Well Construction - GW1_20240208

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• WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well
elll n or Information: � -
v�- r 1ud,(1Crt Ci'V11LtC(r
14.:WATER•ZONES 1:'
WellConnttrractorNpa�me FROM TO DESCRIPTION
NC Well Contractor Certification Number `f'"' JY ft.
ry� 15.-OeUTERCASING(for multi-cased wells)'OR LINER-(if-ap livable):-;; .
/, /� //;i5 �e/�/ V�,;/ ' _ 4'C FROM TO DIAMETER THICKNESS 1j MATERIAL
o an /f / (( G ((/ (�1//L4: ft. Jr 7 ft in.
Company Name �I _$/ / � �� I /�� w
N.
`� 16.INNER.CA ING:ORfiUBINGi(geothermal clost d=loop)
2.Well Construction Permit#: -J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1G County.Stale.Variance.etc.) C.) ft. ) ft. i4 V. in. r-, ( L(! ) 47i ..
3.Well Use(check well use): - V ft. �/4 J ft. 6 in. \IJ L (J V
Water Supply Well: -17 SCREEN•:: . -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural - ❑Munici al/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Di"esidential Water Supply(single) ft. ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) .,18:GROUT::,.:, '�' •---. -
-"- --. _
❑irrigation ❑Wells>100,000 GPD . FROM TO , TERIAL EMPLACEMENi:ETHOD AMOUNT
Non-Water Supply 1 Well; ft. 00
ft. . i • prsiLL )
❑Monitoring ❑Recove 0
ry ft ft
Injection Well;
ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation
"19:.SAND/GRAVEL PACK(ilapplicable):- . : '.-- -. .;.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage, ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ::20.DRILLINGLOG(attach•additional sheets if net essaiy)s:: `, s.-^ -r.,r.:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM Tro DESCRIPTION(rotor,hardness soil/rock type,grain size,etc.)
4.Date Well(s)Completed: /---q-'d�Well MO
Q iL a ft. �e/D C.
la
�a s h ei/ soon •
5a.Well Location:
�( ((��.,,(� p�Nnp �,:o ft. L% 7. �� .s«
1)OV1N0,�. ` ,�O1 Yiic TW& kO 0. S 41 ft. Y)0 It. & Glatt
Facility/Owner Name Facility ID#(if plicable) ft. ft. ^ r- ,s".1 a ,-
n 3 -,fl 4(r'r ! rya it I / !ti✓ ii rl �._� ft. ft. `�- a�E.
% lI l..;L,,
P�ysical Address,City,and Zip ft. ft. �'LD 0.8 2024
. Ge..n ion o g QW-l J V l , 21C'REMARICS;=r ::,
1111C$e't".3i1Qii P:`'caii'rg UAi31
.
County Parcel Identification No.(PIN) CAti QZ'x
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
lat/long is sufficient) Q%� (� 22 er 'cation: i
361.0 1,-LVZ� N O v► (0 6 1 40 W l ✓d
6.Is(are)the well(s): Permanent or ❑Temporary Si nature rtified Well Contractor Date
l
By signing his form,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or limo 15A NCA 02C.0100 or 15A 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 remark section or on the track of this form. 23.Site diagram 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 construction info
construction,only 1 7W-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
CO9.Total well depth below land surface: w (ft) Submit this GW-1 within 30 days of well completion per the following:
, For multiple wells list all depths ifdii ferent(example-3Q200'and 2Q100)
10.Static water level below top of casing: .3 0 (ft)
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
1 •
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: O/�tY f/ 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
n Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 'i Method of test: / h
13b.Disinfection type: i- /y L-/ Amount: 3 pints