GW1--02529_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Informatio�ni: �!�' %?,CC, nV10 Pi I !--' / /J//6-rn 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
7Z ft. 50 ft. j
03‘ - ft.' ft.
NC Well Contractor Certification Number
15..OUTER CASINGfor'multi-eased'wells)-OR-LINER(if-opelicable)-.1:': ', .
2 . / Ato//1 WC) I a//H
, FROM TO/ �DIAMETER THICKNESS + MATE AL
Company Name
-f1 Mt `Y' q f t 6 h, in. Z.�e). I /,i/vc
f Ll =16.INNER.CASING:OR-TUBING:(geothermal dosed loop)" ,:` '.'.: .`-.::
2.Well Construction-Permit#: •�/ 7 a!if` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Ijtesidential Water Supply(single) fr. ft. in. -
❑Industrial/Commercial ❑Residential Water Supply(shared) -
:;1�i
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-19..SAND/GRAVEL PACK(if applicable) ..' : - ' '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary):: = _ .- : ..
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/racktype.grain size.etc.)
0 ft. ft. r-c-d /
ky
4.Date Well(s)Completed r 1-/a'f Well ID# /Z ft '70 ft a 1 s
Sa.Well Location: ;-e 3
' ft. T ft. b he e "-late_
/- ,4 /�'0 Arts / tax if if f. 600 ft. / / /! —Sr Pli e 9'UCDh'i?=
Facility/Owner)Name Facility ID#(if applicable) ft. ft.
Physical
/Addf�ress,City,and Zip ft ft. r n
/'/A24vi ()% 063—0/lu 21:REMARKS..:
_
County Parcel Identification No.(PIN) ? r'
if,:- i; -- , l un
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f°�IC``J�
(if well field,one Iat/long is sufficient) 22.Certification: ,
50, /5/00 "d N gO; V 7/6/ w .6./0 3`ia -VI
6.Is(are)the well(s): rmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the well(s)-was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or "INo 15A NCAC 02C.0100 or ISA NCdC 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 remarla section or on the back of this form.
23.Site diagram or additional well details:
S.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: 60� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100')
24a. For All Wells: Original.form to Division of Water Resources (DWR),
a 10.Static water level below top of casing: 3_ (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
filmier level is above casing,use"+"
11.Borehole diameter: ��� (in.)
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ✓-O-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 27699-1611
13a.Yield(gpm) l , Method of test: f1'I.
13b.Disinfection type: /i/T/i Amount: 3�/.9--ks"