GW1--02877_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.We Contractor ormation:
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14.WATER ZONES 1 '
Well CM-rector Name FROM TO DFSCRIFIION
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NC ell Contractor CettificationNumber L ej 15.OUTERCASING(for.malti�cesed�v )ORLiNER(ifap l))
L FROM TO DIAMETER rti1CiQVFSS MATERIAL
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Co yName W/,
1/ y •4 INNER C ING OR"TUBING(geotlierroal etosedaoop)' MATERIAL
2.Well Construction Permit#: /v" ��..0 /� FROM TO DIAMETER THICKNESS
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List all applicable well construction permits(i.e.UIC,Count':Stag Variance,etc.)
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3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OM ctpal/Public it. R. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) !t ft. is
Industrial/Commercial °Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring °Recovery ft. ft. - __ __ _ _
Injection Well: ft. ft.
Groundwater Remediaton
Aquifer Recharge i :19:SANDIGRAVEL PACK Of applicable) ., - .
Aquifer Storage and Recovery °Salinity Barrier FROM - TO li MATERIAL EMPLACF.MENTMETHOD
Aquifer Test QStonnwater Drainage f ft. YA-1L6t_Gt. bilei Giv
Experimental Technology °Subsidence Control ft. R
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional stieets if necessary)
FROM TO DESCRIPTION(color,hardness.sollfrack type.aura size.etc-)Geothermal(Heating/Cooling Return) 0 Other(explain/ under#21 Remarks)
/ � 0 g. 0 ft. /'0' C(4,
4.Date Well(s)Completed: /''�JJ`✓ R)V'W( 41?# 16 t�
5a.Well Location: ( G R '75 it
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Facility/OwnerName Facility iD#(if applicable) — -". a. .
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Physical Address,City,and Zip MAY
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] f ae. 1 25- y.,G v -21.REMARKS - -
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County Panel Identification No.(PIN) 1"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well22.Certification:atp6a- A
field,one Ong is sufficient) K/`� __ �3 r� I
?5`9o4`Y90 N W ��4e..D i= 1L1Lx..QL -0Z1-,2f
Stgnatuit of Certified Well Contractor
6.Is(are)the well(s)IPPermanent or Temporary , that the well(s)was(were)constructed in accordance
By signing this farts.1 hereby 1y
7.Is this a repair to an existing well: °Yes or o with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a -.
If this is a repair,fill out known well construction information and explain the nature of the copy 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 GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 5
(ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tjdii fetent(example-3Qa 200'and 2(4)100) construction to the following:
10.Static water level below top of casing: / S (ft.) Division of Water Resources,Information Processing Unit,
limier level is above casing
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1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: W(' (In.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
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12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
construction to the following.' ;
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS�O]NLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
i7� 0 6/'I `�Q �'��V� 24e.For Water Supply&Infection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test the addresses) above, also submit one copy of this form within 30 days of
Amount a j1 completion of well construction'to the county health department of the county
13b.Disinfection type: ` where constructed.
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