GW1--01007_Well Construction - GW1_20240208

♦♦rsuL a.l1l1 O i i'lu'..A it/i/i 1Chrt,V1C➢/()LTV -11 For Internal Use Only: '
1.Well Contractor Information:
�eFfre 1:4Ch42 r / /3r•' t i C e '14rWATERZONES !_
Well Contractor Nan FROM TO DESCRIPTION
•
ft., ft. io/ /Lk,
146 o t = n. ft.
1
NC Well Contractor Certification Number
V!� / a� 15::OUTERCASINGG(for inultii-cased/;wells)OR LINER•(f a`'Ilcahle)`.
. t. ill GC/l /15 u../ .// 4 /J/,i"6 l I it FROIM TO ft J ft. DIAMETER
(9 /�'n THICKNESS�� � MATERIAL�
Company Name l
t-� �/ :16:•INNER.CASING:OR'TUBING:(geothermalclosed=loop) ,:':
. 2.Well Construction Permit#: 3 C7 •� f •"/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC.County.State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
l7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft In.
❑Geothermal(Heating/Cooling Supply) IBIrrsidential 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; O rt. ft.a D4i,n, pd[i;taot,
OMonitoring ❑Recove
rY ft. ft.
Injection Well: • .
ft, ft.
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salim Barrier ••••19:SAND/GRAVEL PACK(ifapplicable)
tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft, ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer a20.DRILLINGLOG(enrich:udditiotialsheets-iftiecessary). -_ -- ..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,sell/rack type grain size etc.)
4.Date Well(s)Completed: 6a q 4-.2-3 Well BM cp 0 ft. /_• �- ft. /a,,� G _ _
(P.J z� �+c c.c.��C
5a.Well Locatio •• ;,1 (s,S ft. 3 d fit. /2�e, / � G° -cy�
`�tLrn .1 (.hrlc-Iia&z" ft. 4 t is �`�Jzllo
Facility/Owner Name Facility ID#(if applicable) fL H• [ F C O .\/E
/ 'o • u A,1 rn3 /ea/1 t. . FEB'L�► 8i`2U24
Physical Address,City,and Zip
^L t1_I �y�5q Udl 1 t--11 .21 RElGIARK.S:
:: Co Y I,V f�n Parcel Identificationa No.(PIN) ffletliyrwwfWWOiOrA
,t'��rtid
• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) . 22.Certification:
3 So D O r2 2 'f N 7 q, .9 /3 L'// W Le
6.Is(are)the well(s): Immanent or OTemporary
of ified Well Contractor Date
/ By signing this 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 ISA NCAC 02C.0100 or ISA 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 back of this farm.
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 G i/-1 is needed. Indicate TOTAL NUMBER of wells
drilled: / (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: o D
(ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf d fferent(example-3 ,200'and 2®100')
10.Static water level below top of casing: 3 -5 (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: .0"/$� (in,) 24b.For Infection Wells:Copytto DWR,Underground Injection Control(IUC)
/� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: / 10� [ ' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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 rr��
13a.Yield(gpm) J 0 ,/f..( Method.of test: )9 i r Permit Program,1611 MSC,Raleigh,NC 27699-1611
I//
13b.Disinfection type: !T Amount: P i/1 r S
\ ti