GW1--02603_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • V
1.Well Contractor Information: -
�j �i Q
t rJUI✓l Imo//JN / �, ia." ACC 14:'WATER ZONES _
Well Contractor Name FROM TO DESCRIPTION
10 1t. ft.
Z036- . ft: rt.
•
NC Well Contractor Certificationrt� Number A 15..OUTER•CASING'(for'multi-cased ivells):OR LINER(if'ap"livable)'.: :'_
//Z. liLi pi I_ y�1 ( "f) FROM TO DIAMETER THICKNESS MAT RIAL
Company Name ;/ (/t�C%D 1 4,//z fL B1 ft 6'' in. , �/_ �//tiG
/- /�y1 j ^ ,/ �,r�1 16:'INNER:CA`7SINGOR TUBING:(geothe'rmal closedlol`oop)'". :- ':
2.Well Construction Permit#:W�/7 we.....
`� ZOe! tr(it/�� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.Slate,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 ft. ft ..in.
OGeothermal(Heating/Cooling Supply) E Residential Water Supply(single) ft. ft. in. •
❑Industrial/Commercial .. ❑Residential Water Supply(shared) ::18:GROUT
❑Irrigation .❑Wells>100,000 GPD • FROM TO MATERIAL EMP EMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. LO ft' &r1ia�,rf e. r>ut�OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
'❑Aquifer Recharge , ❑Groundwater Remediation
19."SAND/GRAVEL PACK'(if applicable)I.:: -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft. '
OGeothermal(Closed Loop) OTracer ::20.DRILLING:LOG'(attach additional sheets if necessary),.' - -•-.. . . .. . :.""--
FROM TO DES RIPTION(color,hardness,soll/rock type.grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
�/ 0 ft. iO ft. ✓Pzv n j I C
4.Date Well(s)Completed:7 �/'2-'/ Well ID# /0 ft. qt../ 't ifuG 5 G--A-.
5a.Well Location: ,C!/ •t ' _ rj _' t,,'(r/Get ft. 300 ft. •
��
l .,. . ft. ft.
�iJ� ' t/a /D! i'I�en� cam^ '._,.`,-
Facility//Owner Name G ��f �Fjacciilityy IID#(if"aQpplieable)""''"`''"2:1:15 ''" ft. ft. _ _
6. U i% �-Ci[. //k /�rt�i( ft. ft t a ... .,°t...i.`V r.,..°'.
Physical Address;City,and Zip fL it. Aprr,, 9 70 74
Cab ctrYa
21:RElVIARlCS: : :'; ::. R:
County Parcel Identification No.(PIN) irft:::; ,i:r,?r, fir;; 3}Ji.
i G.l'u'( / OO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: .
35,z73906 N ®. VSG/1/ W 4. q—/..� /
6.Is(are)the well(s): lief a manent or ❑Temporary Signature of Certified el!Contractor Date
By signing this form.I hereby cert fv that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or h11'¢0 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 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 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: 3C7C7 (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@100D
10.Static water level below top of casing: (it)
) 24a. For All Wells: Original form to Division of Water Resources (DWR),
rS ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing;use
�f"++"
11.Borehole diameter: (� (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
//ff Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A 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) � _ Method of test: /7)4 Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.(Disinfection type: !197-11 Amount: 3/11r141S