GW1--02548_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor InformatiL
• '
ke/(J 1J/r1 /7-e,/ /Ario-PN P/C-6 14c WATER ZONES ;;
FROM TO DESCRIPTION
Well Contractor Name
/36ft' /5'5'ft
•
2,036 235ft. ft.
NC Well Contractor Certification Number 15.OUTER•CASING(formulti-casediwells)'OR LINER.(if ap licable) c=,
/ �//f//�, FROM TO DIAMETER THICKNESS MATERIALf
/� ! /oti��IS (, I All., y/Yzft 66 ft_ 6�� in. ../ '4 fL C/
Company Name tJ T
'7 )) 16:INNER.CASING:OliTUBING:(geotherinalclnsed-loop)`
2.Well Construction Permit#: '22.. - / .7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perntils(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 rt. it in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft in. •
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL kPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' (20 ft. 'eiT rlt)h -e. bureCt
❑Monitoring ❑Recovery ft. rt.
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.DRlLLING-LOG(attach additional sheets if necessary)":: -"..::.-,-:,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rock type grain size,etc.)
�y a ft. c, ft. ,/
4.Date Well(s)Completed:d-A0^�l I # .2/6Well IDG ft. & ft 5a/N�/$..f0/f) e-
Sa.Well Location: 6 6 f t. e0 ft. ('O je7 CO 1"GL a }"Gi V e
7 ( // / �. ft. ft. �J
QtdOa /OiIGG � E�45�
Facility/Ownerne Name _ / )/ `` Facility ID#7 (if applicable) ft• ft -_ ,
dl.3 F -%ob- -i`t 4 W hatA) ft. ft. 4 ..,_..L...'iL.,.i. ,F X.-,
l;hysical Address,City,and Zip ft. ft• kn n:L. s Zt7i
,
05-/4/2_003- f -21:-REMARKS: , \
/
County Parcel Identification No.(PIN)
OW Ca moo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
IaUlong is sufficient) 22.Certification: tl
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 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 information 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:
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: C (it) 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: 34. (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
?Twiner level is above casing,use"+" i
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:_ %8 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1. "i14,1 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 WE LS ONLY: //fJ 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) '/ /J Method of test: /�!✓✓ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: I7 T'! Amount: .5 /"/i9/i