GW1--02543_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
I.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION
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rt.' f fr.
NC Well Contractor Certification Number 1 15..OUTER CASING'(for multi-eased wells)OR LINER.(if ap'livable)'•: -
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IIIImo- FROM fL TO rt DIAMETER in. THICKNESS ;Cora an Name It 11 It I, 2 13 I I I a.6 1 t/1, e
Company
/1/ "16:INNER.CAS`ING:OR TUBING:Neotherrnal closed-loop)" :: , ,,
2.Well Construction Permit#: •(/� 3- 3) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. • in.
3.Well Use(check well use): rt. rt. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fu ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. -
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO i TERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: �l ft. c-) ft. �' ` �..�Q
❑Monitoring ❑Recovery �ft. rt.
Infection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)": -
DAquifer 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)::::=- ..*-.'• .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To D •WnTI,ON(color,hardn ssuirnck e,groin size,etc.)
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4.Date Well(s)Completed: 3 t_ Well ID# _ - wft. y.5 ft. g:ILL.Q.....„._
5a.Well Location: ;..i. 1-L ft. 3 d(j ft. 1 Q 6 c c _. -
c f ft. ft. t
'f acility/Owner Name Facility IDft(if applicable) ft. It. I ;
it
Physical Address,City,and Zip j •
ft. ft.
2 a71174
u.nibn "(N 21:REMARKS; .`";"; . . . . .
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one llaadlong is sufficient) I 22.Ce ' cation:
if 1 I3 Q Jf 9 N l� 0t `-[5 q W
6.ls(are)the well(s): ❑Permanent or ❑Temporary Si a[ure f Ceni ed 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: DYes or No !SA NCAC 02C.0100 or RSA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information nit explain the nature of the of this record has been provided to the well owner:
, repair under rc21 renmrlo 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: (f) 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 2Q100`)
24a. For All Wells: Original form to Division of Water Resources (DWR),
• 10.Static water level below top of casing: �� (ft) Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
If water level is above casing,us•+"
1. 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program, 1636 MSC,Raleigh,NC27699-1636
12.Well c'.• ction method: 1 "cY" 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.aug:,rotary,c .1e,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) q Method of test: 6,:c Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13b.Disinfection type: ik-Tp\-- Amount:41— '