GW1--02544_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: -
k_,/lL/ .J e, k / A.,....„ /c :14:VATER ZONES . -
•
Well Contractor Name FROM TO DESCRIPTION
/ R./HO 7 .ft. i
NC Well Contractor Certificati//on Number /) -.15.. G(for,multi cased wells)O&INNER(if sp"livable)_._.:. :
/ / , 1#all.5 I 'd f ,//rl// FROM TO DIAMETER THICKNESS MATERIAL,
Company/Name ` L v I /�/ /// y� ' �/-+Lft. 7 3 ft ! %it in. 0/7.�i . V C
.2-z l/i} v .t16:-INNER:CASING:OR TUbBOINGi(geothermal closed=loop)i'.,.'• '- ..
2.Well Construction-Permit#: �j-Tj FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construttion 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.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in, .
❑lndustrial/Commercial ❑Residential Water Supply(shared)
::18.-GROUT::"[ .�:: . . .
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL E JFLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft c_
1ivn`-f�10 ftitL_ r--otire'd
❑Monitoring ❑Recovery ft. ft. L�
Injection Well:
ft. ft. •
❑Aquifer Recharge ❑Groundwater Remediation _
"-19.SAND/GRAVEL-PACK(if -::. ` -'.... ;..:::.-.: ..` . . . .z
❑Aqui('er 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:DRILL•ING LOG'(attach ddditional sheets.if necessary)>;.=" • ` .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solUrock type gain size,eta)
3 „I/y�� O ft 2. S n, C /cc r-P ecl
4.Date Well(s)Completed: Well ID# a_-ft. 1p ft _,,�ll�t})
5a,Well Location: / / d 6 it. 3 f. IT ra V e I ` h d
Facility/Owner Name Facility Mt/(if applicable) ft. ft. 5'
� ft ft.
/O /% /p1 S/S . +.., .JL1 Ze
�, .. . . :.
Physical Address,City,and Zip /�/ �) ft ft. 5 E n :..'L.r•,q•'; E._,y.;•,.
/MO4-t o6—z` O-007 2l REMARKS:_ ::-: :.;'::. -. `.-....-:-..-..-APR'''''
-LU2�f• `-::...:.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L .w i,a J,
(if wellll 5�
field,one lat/long is sufficient) �/ 22.Certification:
3.5 Z D 5" N O, 75 Za5 ,/q W t
3-//-Li/
6.Is(are)the well(s): '9rPermanent or ❑Temporary Signature of Certified Well cto 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 ' No 15A NCAC 02C.0100 or 1SA 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 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
J
9.Total well depth below land surface: / 00
(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 ctd2/2 100')
3 7 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use// A"+"
11.Borehole diameter: Iz (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
�j Program,1636 MSC,Raleigh,NC!27699-1636 -
12.Well construction method: /C -444-
(, 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
�) •f/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:/
13b.Disinfection type: //7" / 2 Amount: //''t-ff