GW1--02605_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: V
1.Well Contractor Information:
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14.=WATER ZONES
Well Contractor Name , FFROM /TO�j�1 DESCRIPTION
Za3!�/ 00
fit / D CJ ft.
l?�jft, ft.
NC Well Contractor Certification Number
�'�//J /1/ 1� -15.:OUTER CASING:(for multi-caieed`wells)OR LINER(Wan'licabtte))•-••�:'
a/ i'//t.t/l/4 t A) 11 4//1„;� / ft FROM TO it. /f ER m. . THICKNESS g NA/J,VC..Company Name 'Pi 2L 9� C) I U
16:INNER.CASING:OR TUBING(geotherinal-closed-loop) --
2.Well ConstructionPermit#: fi/1,4_W)�'z-oz-3--cY)/ 9 FROM TO DIAMETER THUCIC4ESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,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 ❑M cipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) I ? sidential Water Supply(single) ft ft ' in.
•
❑lndustriallCommercial ❑Residential Water Supply(shared) . .
❑Irrigation ❑Wells>100,000 GPD . FROM TO 1, TERIAL . EMP EMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft, 50 ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge s ❑Groundwater Remediation
"19,SAND/GRAVEL PACK(ifapplicable) _. ::'- • = '•' '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer ••20.DRILLING LOG(attach additional•sheets ifnecessary) : . _ .
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. a it. 0lcv.,
4.Date Well(s)Completed:9�/`/5�l'Well ID## ✓ ft. 3t, ft 6 a ,,0 r 4 s c
•
5n,Well'll/L , -_
Location; )) fJ ;. __r , ft ad ft. I/ KYt..e, Pr I?'e
Ah✓ / -:1) / 4 --am ,c ft 460 n: // /1
Facility/Owner Name' Facility ID#(if applicable) ft. ft.
/aza S� ILL Z.1.
ft ft -. -,:. .. : rya ) .
Plsysical Address,City,and Zip ft. fit. ADD 9 C. WO/j
•
21.REMARILS: '._;_• r.; .r..
County Parcel Identification No.(PIN) Inf:. , is74i5f>"47-,9 UE)i
D ICti-3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one lat/longg is sufficient) � 22.Certification: �j !/ / [� 7 N 7,e�i ow
.
%2 g3 W /6�/ �- 7 — /i— zi"ee
6.Is(are)the well(s): IP'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance wi h
7.Is this a repair to an existing well: ❑Yes or l71N'QD I SA NCAC 02C.0100 or 15A 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.
u 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: ©� (ft.) Submit this GW-1 within 30 daysycompletion of well per the following:
For multiple wells list all depths ifdii different(example-3Ca 200'and 2©100) g;
t >? 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 27699-16I7
If water level is above casing,use"+"h
11.Borehole diameter: /v (in.) 24b.For Injection Wells: Copy.td DWR,Underground Injection Control(IUC)
//�� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �._G/YeeTh, 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
I WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) / r✓ Method of test: /'/)✓ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: t-)2 Amount: /IP .f
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