GW1--02599_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:TeFf re/ 7cckter/Ga v/.1V T a,c/fse n 14.•WATERZONES : : -..: ': ::.:--`-:: :.. _:
Well Contractor Name FROM TO DESCRIPTION
II
-, fr., ft. G e3(05 Ix 1,3.5
ft., ft.
NC Well Contractor Certification Number 15..OUTER CASING'(for mul/ti4ased'wells)°OR LINER Oran lit-MAWa -'; : .
FROATERIAL
!/, L, yl�ti h//. s w-e1/ Via 2 �R/C. /f ft. TO -L7 ft.
pd in. ThDIAMETERICKNESS t'a.5 1 ypC
Company Name
'A
n ._16 R.INNECASING:OR TUBING'(geotherinal'closedloop)`- . - -
2.Well Construction-Permit#: �4 ^(�', oc o _OC)/(%F FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 113'Residential Water Supply(single) g, ft, in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18:GROAT
❑Irrigation ❑Wells>100,000GPD • FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: d ft. cAD ft. G/Q�� p
rt Q `�
OMonitoring ❑Recovery tt. rt. JJ
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK-(ifapplicable) ::-• : -` - • •'-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
0 Geothermal(Closed Loop) OTracer :20;DRILLING LOG(attach additional sheets.ifnecessary),::-:- :. :__,.r... :`..-':
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soIDrack type Brain size,etc.)
�1�,/ D ft. / /•7 It. 1y eiicc GtJ c
4.Date Well(s)Completed:3---),. ...a'/ Well ID# `(3 ft. '1 tt•'�It. S11 e l( /,5L .-e 5 L
Sa.Well Location: MN-1';
f�^ p1 /j Li Li ft. / y oft. '/tee SL�e
i •
t Lr\c, . 1 I Lr 11 1'; t i fv ft. l L/ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
6, e ti a fS /-a.I'L ClecL
ft. ft. 6 :: , ; 4� : ' A�
Pitysial A ress,City,Kid Zip
Y IVIft ft.. Aup 6) a Iu�
.21.REARICS. 7,.:: .- :.,:._.:'.;. .i": - ... - -
County Parcel Identification No.(PIN) . Ir1;.a7;'v.i' 7: ?•-^ Re,,;,.p t[—.s
Div(.i 30C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36 r ,)-7aa.s N SoiW56.o w s. _3-ia�a2-1
6.Is(are)the well(s): mmanent or ❑Temporary [ ur of 'fled Well Contractor Dale
_ By signing this form,Iherebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &li 15,1 NCAC 02C.0100 or I SA 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 GkV-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.Totril well depth below land surface: • H (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`)
24a. For All Wells: Original i form to Division of Water Resources (DWR),
0 10.Static water level below top of casing: g D (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
i
l� �g (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
//
11.Borehole diameter: Program, 1636 MSC,Raleigh,NC 27699-1636
n
12.Well construction method: /`0/72 ry 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) / 0��//0 1 Method of test /+A f/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: n/ /7 Amount: .. 7 Pi rrk-C