GW1--02601_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1. ell Contractor Innation: (�,/ (f r
i A i
1 don �13i6b l/ f4/is 14.WATER ZONES.,
W I ContractorName • FROMecp DESCRIPTION
5ft. ft. - '
tt.' ft.
NC Well Contractor Certification NumberNei(\ 15..OUTER CASING'(for multi-cased'wells)ORLINER(if ap llcable)�I�� 11I I I I FROM TO DIAMETER THICKNESS MATERIAL
H�ft. jl ' ft. tO73 t/in. 2 5 j7
Company Name r� ( (/ t
5
/j "� f t( J -16:INNER.CASING:ORTUBING'c(geother'mandosed-loop); ..
2.Well Construction Permit#: (V0�/ Vv FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, ounty.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/PublicAesidential
ft. ft in.❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft in. -
❑lndustrial/Commercial ❑Residential Water Supply(shared) •. .
. 18:
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT MET OD&AMOUNT
Non-Water Supply Well: G ft. ft. hei en1 i i , a red-
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK(ifapplicable) - . - -
❑Aquifer Storage and Recovery OSalinity 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).;,-;: :-. .:.. ' .,-:.. :-•.- .•.;°•
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft. y fr. clot
( � -1
4.Date Well(s)Completedx. ) —1`OG Well ID# sr ft. ...?1,...?1, ft 54 n Y
53
Well Location: -.�. ft. )�s it /�t��5 ��
�( P �j`�C�V'— as"_ '� a .—) Sit f7�ft' 9/ra v1 I fe.-... •
Facility/Owner Name F:f dity ID#(if applicable) ft. It.
ci(?)( ') � at t n 4-� /t ft. ft. ;
P ical A ress,City,and Zip It ft.
Cj�..nus 1PR2 )fi2r
21:'REM ARKS -
County Parcel Identification No.(PIN) lr>•tp 7r••• 7-''• P''`'f''' '`•-" '1,"
C)W/20C)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one IaV[[long is sufficient) �(n u fl 22.Certification: I > /�•
//, t /t
�jJ ,ri166o N l)lJ 't� L� J W 7lP v��Y' 7140 �� 3—,"i- Z
6.is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.tvitlt
7.Is this a repair to an existing well ❑Yes or No RSA 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 u formation n 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 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: L a o (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if difierent(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: �0 (fL) •Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"11.Borehole diameter: G 74 "I (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '(1 Ro/Af2 I
�' 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: 0 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
NYC)U . Method of test:
13a.Yield(gpm) �r' Permit Program,1611 MSC,Raleigh,NC 27699-1611
11 l
13b.DIsinfection type: ri-(`T` Amount: 1pi—