GW1--02556_Well Construction - GW1_20240426

,_ WELL CONSTRUCTION RECORD(GW44) For Internal Use Only: ,�
•
1.Well Contractor Inforrmation: �5 1. `�
�ek 1`rnf
V i ` ,IiCkt l�S'aidgr1 J C.,kS01'1 -14:-WATER ZONES;.:;:. •'r.:i:,t.:r' :•::._- -::
Well Contractor Name s FROM TO DESCRIPTION
NC Wel1.0 a or Certification Number �6 t. ft, r 2 D
!� 15..OUTER.CASING`(for Multi-cased iells)-OR LINER-(if•ap licable).' ''
�L, rNA• ��°� \ r�_ �'Ij y �\\�N FROM TO 1 MAME ER THICKNESS MATERIAL
Company Name ` Y�l ` �J '4 _i ft. lI S ft. :6_i �a in. 6 r - 1 p`lc
p��� ��)) .''1166:•IINNER,CASING:OR'TUBING(geotherinaTclosedd hoop)' I- •V>"-
2.Well Construction Permit#: r5 1C�e 6'CA I FROM, TO DIAMETER THICKNESS MATERIAL
List all applicable well constru Lion permits(i.e.U1C,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 OMunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) IEResidential Water Supply(single) n• ft. in .
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000GPD • FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2.--0 ft 96er f p o ore"
❑Monitoring ❑Recovery ft. ft Injection Well: ft. ft.
❑Aquifer Recharge • ❑Groundwater Remediation
: 19.SAND/GRAVEL'PACK(if•applicable)" : - . s: . ' -
❑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) OTracer •:20 DRILLING-LOG(attach additional sheets if necessary) '. _ -
❑Geothermal(HeatinglCooling etu ) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saWtnck type main size eta)
4.Date Well(s)Completed: 1 4;• -ILI Well ID# i® rt. 20 ft t.A �,`
5a.Well Location: ` -' i7,7, 1, it. 1 00tt �� sk
i ts\ `t t ' ; ft ft.
Facility/Owner Name \ Facility ID#(if applicable) ft. ft.
Physical Address,` YYYCity, •
l=City,and Zip
ft. ft. '
4k�l� 15 E55 •2L-REMARIGS.. . . :.:.:.. .. . APk-.,6 i).'.LUL4 .:-':- -- .
County Parcel Identification No.(PIN) - F
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Irt`� •```^` ,r'r":D:�' J '
(if well field,one lat/long is sufficient) Q 22.Certification: r1
6.Is are the well(s): It/Permanent or ❑Ten ora Signature--offCe�rtified Contractor Dat
Is(are) p ry
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 eiNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fall out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarlr section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobefDPT 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: LI v C) (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(Q200'and 2(4)100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"l
11.Borehole diameter: / > (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A l V iteA 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) 5 Method of test: IT ‘r Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: 14 1 kA Amount: 1 t t-'•
4-