GW1--03435_Well Construction - GW1_20240611

•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:`
46I V,i" �I k ! Ic-r 4-e-
1 14.WATER ZONES
Well Contractor Name TO DESCRIPTION
•
06,36 rb- rt.
ft. //. . ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(If ap licable)
Z, A11I5 t ) I a ki C FROM�t TOE DIAMETER THICKNESS MATEERIAL/
Company Name L./ 4"//7i' `74 It. 6/O in. I A7 '( f- )V
Z[� - 9 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County.State, Variance,etc.) ft. R. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
❑A CUItuCdl FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public It. rt. in.
OGeothermal(Heating/Cooling Supply) 131�idential Water Supply(single) ft, in.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft' 30 R• ben'1`O ki%bit no t.(i`
❑Monitoring ❑Recovery ft. rt.
Injection Well:
ft. n❑A uifer Recharge OGroundwater Remediation OAquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ry FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage l' ft
❑Experimental Technology ❑Subsidence Control rt. 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 type,grain sin.etc.)
// (5 It. ft. c1 a
4.Date Well(s)Completed: 7 " '"7A'Well ID# 8 ft- . G ft- -e i,/ S jq,-f-'-ri
5a.Well Location: '•1 a 0 It. 4 ' I't •
/ . ` 'u, e S lc (
So0...n, 4)1 /so-. qy t- ft. ((]I f
Facility/Owner Name Facility 1D#(if applicable) It. rt. i
(P 31 c\ /,-0, (�� s «1B ft. ft �=-�- V C.
Physical Address,City,and Zip ft. ft. J U N 1 1 7024
iiiiipr-_, 0/ -/3�j -0064 21.REMARKS
Kilo:rr...iwt'a ft'�-ra/v•-,1 lint'
County Parcel Identification No.(PIN) ry,(; I;.7.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35./�j/6j N g4. 37/ /50 W ,; �� �(Z'E'
Z0-Z7'
6.Is(are)the well(s): li3Permanent or ❑Temporary Signature of Certified Well Con ctor %�� 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 III< ISA NCAC 02C.0100 or ISA NC,IC 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 remark section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: .--200 ( completion of well ft')
days
Submit this GW-1 within 30 per the following:
For multiple wells list all depths if different(example-3Q200'and 2®100')
t 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 30 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
` % I,
11.Borehole diameter: (t � (;n,) 24b.For Inlecdon Wells:Copy to DWR, Underground Injection Control(IUC)
J Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 41 T I2 0 TA 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
*� Permit Program,1611 MSC,Raleigh,NC 27699-1611
v
13a.Yield(gpm) IO Method of test: 4 I Z.
13b.Disinfection type: //T-// Amount: rl I'-s