GW1--00954_Well Construction - GW1_20240208

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WELL CONST"UCTION RECORD (GW-1) For Internal Use Only:
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1. JWell Contractor Information:nf � t
1G i�:vr \ :6\4-16GlV1ll 7,co,c,,C St.,f'1 14::WATERZONES
Well Contractor Name r FROM TO DESCRIPTION
7T� ! fI 5 ft. ft.
V v . 1 se, oft. ft. .
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NC Well Contractor Certificatjon Number . .15;OUTER'CASING(for multi-cased wellsy OR LINER(if applicable)".::';-'-:-. -,•s•-
y o� (� FROM TO DIAMETER THICKNESS + MATERIAL
1...� � \\‘S � \` �/C-i\ \ihG) +t' ft. 145 ft. !_f/ty, in. 1 12'� If
Company Name J ® F'
.:16;INNER CASING:OR TUBING(geotheriaalclosed=loop)?; =•`-.:r":' -..•
2.Well ConstructionPermit#: 2 . -'€:,, �j 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constntction perinits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(cheek well use): ft. ft. in.
Y Water Supply Well: 17:SCREEN
-FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic . ft ft in.
❑Geothermal(Heating/Cooling Supply) llResidential Water Supply(single) ft. ft. in. -
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT;
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft z b ft. n
❑Monitoring ❑Recovery ft, ft �����
Injection Well:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation
'19.SAND/GRAVEL PACK(if applicable)'- - _, =.;- - -
❑Aquifer Storage and Recovery OSalinity Barrier. FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
[Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer -:20,DRILLING LOG(attach additional sheets if necessary)::': .-,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotllrock type,grain sue,etc.)
fir. b ft. -� ft. LI ry t v h t,I c.y
4.Date Well(s)Completed: i,>vI2� Well ID# /0 ft '.2-6 ft ( `k r-rx l
5a.Well Location: G • - d ft. 100 ft .h Le 5 f A'
roJrN
Faacciillityy/Owner Name Facility ID#(if applicable) ft ft.
y ft. ft. F=� e. : `,
`?x�12. Ge i�i�t9 Cv 1.-) 1.� v I:r i ��,�,,..,:
Physical Address,City,and rp ft. ft. FrD Q 20
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1. v-v, b c)8 30g62 2l:'REMARKS yr r+.. tl_.
County Parcel Identification No.(PIN) lflfflrtr.sdt°),1tY^t:wk..d.,,.Utr
DWQraoG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
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(if well field,one lat/long is sufficient) 22.Certification:o�
ra t 1 .11° 8 Ea
N �l ow W M�
%�/v1,Z t IS 6 /2-q
6.Is(are)the well(s): j FPermanent or ❑Ter orn Signature of Certified Well Contractor Dace
P IY
By signing this fort,I hereby certify that the well(s)was(were)constructed in accordancewith
7.Is this a repair to an existing well: [Wes or it No 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out NOW 12 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 back of this fort. 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 1 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: ® 1 (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 r@t 100)
10.Static water level below top of casing: .6 I (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing.use•'11+ Information Processing Unit,]617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C) 1 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/n�
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Pr 1 r 12.404ci t••''/ 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
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) 1° Method of test: IN k(-
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13b.Disinfection type: l t gqam l 14 Amount: I Nf IN4 I ..
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