GW1--02547_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
•
1.Well Contractor Information:
ted/Oi+7 6‘1
`d4:'WATER ZONES :-�
Well Contractor Name FROM TO DESCRIPTION
/. - ft., 205".
Z+03 V _ ft.' ft.
NC Well Contractor CertificationNumber '
n /� 15.OUTERCASING(for_multicased wells)'OR LINER(ifap licable)
., /' ,/1u//s ) '/ i I i/ -i//� FROM TO DIAMETER THICKNESS ii't
fL ( j fL // in.
Company Name 3
Z, 2 •16::INNER.CASING:OR-TUBING°(geother'inal closed=loop):-:
2.Well Construction Permit#: . / / FROM TO DIAMETER THICKNESS MATERIAL
`
List all applicable well construction permits(i.e.UIG County.State.Variance,etc.) ft. ft. . in.
3.Well Use(check well use): ft. ft. in.
4 Water Supply Well: 17i SCREEN'
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft. ft. 'in.
❑Geothennal(Heating/Cooling Supply) jitiftesidential Water Supply(single) fL ft. in. •
❑IndustriallCommercial ❑Residentiial Water Supply(shared) ;lti:
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. OW ft.`,j.1„�.,,-),, i 'o( rcd
❑Monitoring ❑Recovery ft. ft. �/����
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-19.SAND/GRAVEL PACK(if applicable):"<: •. -. : '
OAquifer 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) ❑Tracer '20.DRILLING•LOG-(attach additional sheets if necessary):-,-. -• = i
FROM TO DESCRIPTION(color.hardness,sollrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return)) ['Other(explain under#21 Remarks)
.ZT� Z�! p ft. f d ft. �-�d c�j 0.
4.Date Well(s)Completed:Z ', Well ID# Jo ft. 3 ) ft. , d S r a. 7i
5a.Well Location: 3a ft' /rL/ It. /„/a 5let-f-c
44--- _.i.....4 iet t r*-3,._ c•,-,?'e;:. .-•-c,
Facility/O�wyner Name Facility ID#(ifapplicable)' a tt' ft.
lJ /J / l ft. ft. t k:'it..,i. ;•z' 1. ' - ,
Ilitysicaal Address,City,and Zip / �/ ft. ft. A p p c� 2021
/.if.4/6/1 •
0 "/97�-0/ 21:REMAR1cs .. f R �.. .
County Parcel Identification No.(PIN) l ref,3: "•{'-:. P .
: _r'..t,.-:a /;''s;
L):e Ct3CG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 t/.9i 6S 5.5 N .d 93' o 2‘ W 7'�4"Y ,t) ___Z Z-2 S'-Z
6.Is(are)the well(s): 2Permanent or ['Temporary Signature of Certified Well Contractor Date
- / By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or I?lVo 1 SA 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 it formation 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 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 constriction 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: z (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@100) 1
. / 24a. For All Wells: Original,form to Division of Water Resources (DWR),
10.Static water level below top of casing: . 7 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: At o (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: O-lG 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
�J Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7� Method of test: ff!PP_
13b.Disinfection type: f? 7// Amount: >o'/-s