GW1--02575_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • ' • V
1.Well Contractor Information:
(l Qlvi 6 ) k / ✓l,.+e A Co{i
Well Contractor Name ,,• FROM TO DESCRIPTION,
Z036 _ (o5rt. �oSrt. � •
ft. rt. i
NC Well/Contractor
Certificcation Number / 15.OUTER CASING(for multi cased wells)OR LINER(if ap livable)
/z . , e....t l i f t ie J,( ��'O/`' FRO TO DIAMETER THICKNESS MATERIAL
Company Name , /' IIA/ 000CVV/ 0 LI Yet 5�y' ft. / 7g-in. r 25 1 pc.G
J q� .'16.INNER.CASING:OR TUBING(O :(geothei•malclosed-loop), ".r . - _
2.Well Construction'Permit#: ton//3 J __FROM--�.TO I DIAMETER THICKNESS __L A7.--�
List all applicable well construction permits(LaUIC County,Stale,Variance etc.) L -- f=_ - I
3.Well Use(cheek well use): • ft. rt 7 in.
Water Supply Well: 17.sCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mu�nicipaLfPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) C esidential Water Supply(single) g, ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT=:'
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- /0 R. beef 1,F'e pUreal
❑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.
OGeothermal(Closed Loop) OTracer .20.DRILLINGLOG(attach additional sheets if necessary): .• . - ..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hominess,soWrock type grain size etc.)
/' O ft' 2 O It. re�. c. (0.y
4.Date Well(s)Completed:`7 /1'Zil Well ID# v rL -j j rr. ,.e d. S. cI Its
Sa.Well Location:r $ 1�-- t_� ----Th �5' ft. -� rt.S � n 1'Te
-m,,,,,J p- G $ s et- L _L
. O�+. ...vi.
59 ft. 2OQ R. 11 11
Facility/Owner Name Facility ID#(if applicable)) ft. ft.
C-l-/ -I/ njr. )et✓h-tl ie yG. ft ft ` "-,' ' i i' ' _ .• )
Pjiysical Address,City,and/Zip ft ft. ` "'
21.-REMARKS. :-". - .- r.'. :,, "...2.V.:'`l{L _
County Parcel Identification No.(PIN) -•n 1,?yt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `��' �r '
(if well field,
lo
one lat/long is sufficient) 22.Certification:e__3 N 10.05-'1z-e--, w ,E:cji„.r.,„.„;),4"jr.....„_ .
6.Is(are)the well(s): l3rmanent 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 ii1N'S 15A NCAC 02C.0100 or ISA 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.
i 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: �I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: oSOO (ft)
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!Twofer level is above casing,use"//"
11.Borehole diameter: t. 1/3' tI 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A(1Z Ra•i:A R V 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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) 1 Z' Method of test: 4Q') a
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: ,L/t-i9 Amount: JiiTom' .