GW1--02536_Well Construction - GW1_20240426

WELL CONgTRUCT!ON RECORD(OW-1) For Internal Use Only: 1 • .
. 1.Well Contractor Information:
ft i3 T
12\v e \IL lt- \v-hy\ �f`1 14.WATERZONES. : '
\VeIlContractor Name FROM TO DESCRIPTION
2 6. 6 / art. Z/, ft.
ft. ft.
NC Well Contractor Certification y • 15..OUTER CASING(for.multi-eased rveUs)'OR LINER(dap licable)''.>'.
q� 1 ` , 1( FROhf��� T�O1 DIAMETER THICKNESS MATERIA
,1�� �V ` � �l�-1��) �r`1 •�l�j + l/I/ !� CL �0% in. _a�: PliG •
Company Name J
• ` 16.INNER:CASING:OR TUBING:(geothermal closed=loop) :.- - •<'.'
2.Well Construction Permit#: -• G� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. • in.
3.Well Use(check well use): .ft. It. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. it in.
0 Geothermal(Heating/Cooling Supply) estdential Water Supply(single) ft. ft. in. •
0 Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT :•::
0 Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft• 25 ft G�ei lfcal',te- 1 Jett r-ed-
❑Monitoring ❑Recovery ft / it. r c%� l
Injection Well: ft. R. '
❑Aquifer Recharge ❑Groundwater Remediation
0:19.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. '
OGeothermal(Closed Loop) OTracer .20.DRILLING LOG(attach additional sheets if necessary)' : -_:.
OGeothermal(Heating/Cooling Retu ) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
�-f �) ri I. 6O ft. re it c to
4,Date Well(s)Completed: 2 J J2-=i Well ID# �p ft 3S it r�� [l� f-
5a.Well Location: -4. 3 12. fL b love �- f cif
4%-06CAC V'O � /
. Tec5 If3 IL
CL Sea // f /
Facility/Owner Name ` Facility ID#(if applicable) fL ft.
i
S Z . k/` 1 ft. ft.
`'( 1--.
Physical Address,City,and Zip ft. ft. . 6..- ,.
•
1 ill 1 1 -- iJ �r1,4
i }y"7\d � � 21:'REIVIARICS:. '''. .,. .;_ . r.Q,i � -- ,J
County Parcel Identification No.(PIN) �'.'=f"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certification: f�
36.1 ,Ggq N PQc 3� 13(6 w . 7. �.- SF -Z-(
6.Is(are)the well(s):immanent or ❑Temporary Signature of Certified Well Contractor, Date
By signing thisfornt,ihereby cert fv that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or i o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction in formation and explain the nature of the of this record has been provided to the well owner.
repair wider#21 remark 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
i
9.Total well depth below land surfacer (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@l00)
/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3S (ft•) • Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" r I
r 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �3 (in.) Program,1636 MSC,Raleigh,N027699-1636
12.Well construction method: I•(g 14v /4 n Y 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
13a.Yield(gpm) /D Method of test: 41 r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /1 7-IT Amount: 1 p ve--.