GW1--00993_Well Construction - GW1_20240208

•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j '
1.Well Contrsictor Informationt`-
VekV O r\ \Se.\K. \Go&jk P1 -3---.&c-kS ON -'14:'WATER ZONES.':.: fir: :
Well Contractor Name FROM TO DESCRIPTION
Z 6 60 ft,, ft.
art. ft. -260
NC Well Contractor Certification Number
` ( ` ` ,15::OUTERCASING`(foi•multinsediiiells)'ORLINER(flap liable)
b� �\`‘S �e t\ '1`1 if13 +1M ft. TO
ft. 6 Ile
fn. THICKNESS ESS MATERIAL
PVC
Ra
Company Name -7
J �1 '16;INNERCASING:ORTUBING(geotheciaelclosed4tain . :
2.Well Construction-Permit#: 3� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction petinits(i.e.UIC,County.State,Variance,etc.) ft ft. 1 in.
4 3.Well Use(check well use): - ' ft ft in.
Water Supply Well: 117.SCREEN 7.-",;T:1?:'f'1.?:.:: •:.,:-..7'.':.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. :in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
;1>;.
❑Irrigation ❑Wells>100,000 GPD - FROM TO MATERIAL ' EMPLACEMENT, D&AMOUNT
Non-Water Supply Well: s4 ft- e26 ft r
❑Monitoring ❑Recov V ��1bf1 t'1'rr� �6U�
�Y f4 ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
Aquifer Storage and Recovery ❑Salim Barrier 19:SAND/GRAVEL'PACK'(if applicable) :_- z-:, ,
tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
:
❑Experimental Technology ❑Subsidence Control ft. ft. i
❑Geothermal(Closed Loop) ❑Tracer ;20:DRILLING LOG:(attechiidditional sheets 'riecessay) .-.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(calor.hardness,sail/rock type,grain size.eta) .
o ft /� ft red cla. I 4.Date Well(s)Completed: {2,f t `Z,a Well ID# I b ft. -Zt> ft- 6r-owl,„ G,h.
5a.Well Location: ;,i ..Z it. 61 ft. p3 .y � 1 _ Kl <cy/6
NA-�-4% Ctl io not 5 7 ' .3C-+»+ tL b' € s i G r
Faciliittjy/OwnerNam(e�,,, /� �+ Facility ID#S (if applicable) ft R. P"'+"�„ -j fry.,,V„b
4 l 22 1 �.Je�n/' C X'1' L l� i�C' { ft ft. r 6 r,.s'
Physical Address,City,and Zip it ft '-LB A 8 2024
a._1_. 1.4 ,S O�`b`2. 21 REMARKS 0
lll(if}tif:Wm rPr(c.: .in.
County Parcel Identification No.(PIN) C /QI O +
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
• (if well field,one lat/long is sufficient) 22.Certification:
'3 S r '4 6®ea-- N P . 3C)8-1y b W r• /e.
I k
2-Q l. 12 1 3
6.Is(are)the well(s): CIPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 'Ago ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out know,:well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#2I 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
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: 300 I'
For multiple wells list all depths if different(example-3@200'and 2@100') ( ) Submit this GW-1 within 30`ays of well completion per the following:
10.Static water level below top of casing: 30 , ,,, t 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 _
il.Borehole diameter: / It 1 (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
A
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: l t- 1 .C-4a 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
I,
FOR WATER SUPPLY WELLS ONLY: r 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) S rr Method of test: JA
l r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: FAT(- 4 Amount: ` fliP14