GW1--03247_Well Construction - GW1_20240528

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WELL CONSTRUCTION RECO (GW-11 For Internal Use Only:
1.Well Contractor.Informmaation: •
p •
L • S . ' \�r �- nrk_,- 14.WATER ZONES
Well Contractor Name ?ROM TO DESCRIPTION
'��+ /Qv ft _VO ft.
V ✓ S ft ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap liceble)
Y'C.) -e_vs FROM I TO I DIAMETER. I THICKNESS MATERIAL
Company Name ft ft
16.INNER CASING OR TUBINILgeothermal ceased-loop)
2.Well Construction Permit#: ( W L a 6 Z� I l l 7 1 FROM TO DIMIZTYR THICKNESS MA•IiR{AI,
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List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) -- 1 ft. !]5 ft A,- '° �- J
_{ d f r f a'1%. p✓C^
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3.Well Use(check well use): {tt. is
Water Supply Well: V.SCREEN
DA Cultural FROM TO DIAMZIER SLOT SIZE THICKNESS MATERIAL.0Municipal/Public It ft. in
Cl Geothermal(Heating/Cooling Supply) sidential Water Supply(single)
ft ft. in.
❑Industrial/Cornmercial ❑Residential'Water Supply(shared) —
la.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPIACEMENT METHOD&AMOUNT
Non-Water Supply Well: •
0 fc 2,1 ft L ,t 1
❑Monitoring DRecavery ft. " - '�i T l V ' )1 `r y
dKa./ P ( r1
• Injection Well: •uifer Recharge ft. ft.DA
q 8 ❑Groundwater Remediation
•
❑Aquifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
❑Salinity Barrier IRON TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
• ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESC[UYI IQN(color,hardness soil/rock type,araio sae etc)
ft ft
4.Date 1Vell(s)Completed: 5—i—2* Well ID# ft tt
5a.Will Location: I- ft ft.
Crh ,5 c-oIUbI • R. fc
• Facility/Owner N e Facility MN(if applicable) ft RiMag/i,te ����
13 to -e el l -e ct f►r ►.Y l — D b b --' .ft ft.
Physical Address,City,and Zip ft. ft
l✓l Y ir i 21.REMARKS!
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient)
3 6
22.Certification:
6.Is(are)the well(s): {dPermaneot or ❑Temporary Signature utifi Nell Contractor �_
n Date
By signing this form,I hereby certO,tart the well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or No 1SA NCAC 02C:0100 or'ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifth/s Is a repair,fill out known well corunucnon information explain the naturt ojd a of fins record has been provided to the well owner.
repair under 021 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 static 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 Rerr.'arks Box).You may also attach additional pages if necessary.
drilled:
2-. 24.O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (Ct)
For multiple wells list all depths ifdierent(example-3®200'and 2®100) Submit this GlV-1 within 30 days of well completion per the following:
10.Static water level below of casing: ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR), •
If water level is above coonel use top of casing:
f t. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
II.Borehole diameter: •
C�J ! (in) 24b.For Iojectiou Wells: Copy to DWR Underground Injection Control(lUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Q { a.•riot . _ A . r
(i.e.auger,rotary,able,directpush,hod:etc.) l 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county enviroeuuental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
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24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 3 O Method of test: A i r Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: I i 7-)4 Amount: / n 4✓
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Reaaurccc
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