GW1--03420_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r
C lie„--1.-1 f id bi/ (; /J '&'r y 74 di er 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ao.3 9 '1 �(�O a� r) J a-ceric n ft. ft. 7©)a to a s�� a 9v
NC Well Contract&Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap lIcable)
9). . /l4,/�"5 tie j/ Vr/'///" _ /C ' TODIAMETER THtCKN��S, MATERIAL
Company Name !! ` e /7�Lt �G' ft. ft- Q r to i ;7,J ‘.51*.€1
16.INNER CASING OR TUBING(geothermal cl s -loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n, D. In.
❑Industrial/Commercial ❑Residential Water Supply(shared)
IS.GROUT
jgation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. [7l�I D IL ; rz:46. �O
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
[Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
[Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWrock aru cry
4.Date Well(s)Completed:Z.-a/'a y Well ID# ft. . 3 it
Well Location: "if 3 ft. 3,c 6-(4---1..
Y11: 4---(7 c=kleg k in
^..� nn ft. ft.
Facility/ wn Name Facility ID#(if a icable) TM- rt.
//id0 Concord P ilea y S. Cinc'Dpd ft. ft
nPhysical ddress,City,and Zip ft. ft. r`` }L ?j ' ��„
" ,l -� 21.REMARKS [ t v`L?
County Parcel Identification No.(PIN) JUN 1 U- 2i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: hYertam:;e ' .
(if well field,one lat/long is sufficient) 22.Certification: y DO,. s UV
35• 3 '02415 N 8o • 3 / yy w s-a
-t
6.Is(are)the well(s): ermanent or ❑Temporary Si t C Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or it ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#2I 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 6r/-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: 3 o o
For multiple wells list all depths if-different(example-3®200'and 2@I00) ( ) Submit this GW-1 within 30 days of well completion per the following:
i a 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: Y%, (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: t>ilp fit,' 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) 000 Method of test: At r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 7/c} Amount:3 /. 'I1 /,