GW1--03437_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.�Wedll Contractor formation:
kC will £/L / k/u, t t c,e, 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
W36 ft. R.
ft. rt.
NC Well Contractor Certification Number
I �/ 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Itcable)
az. ri u 111 S 14)e- l f(/� FROM TO DIAMETER ' THICKNESS MA AL
T
Company Name //�L ft, La
IQ ft, 6N in. , Z rya //i/G
Z --- .6---- .6- 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.U/C,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): rt. ft in.
t Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�uunicipal/Public ft. R. tn.
OGeothermal(Heating/Cooling Supply) Cil sidential Water Supply(single) g. n. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO ' MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 30 ft. t i ifr LG /f0�
❑Monitoring ❑Recovery ft. f. 7 /�
Injection Well:
ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 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 DESCRIPTION(color.hardness soWrock type grain size,etc.)
/1 , l 0 it. ZO IL keG/
4.Date Well(s)Completed: '�1 c LI Well ID# ' oit. lam/ n' „�rl
5a.Well Location: i' 30 R. yb n- the 9"9E,.
4nn itu G• Zii+ec, i,J%ru.r;i w ll ii ) Li S ft. �5 i/ i/
Facility/Owner Name Facility ID#(ifapplcable) rt. ft. ,-- - ..
( 4.is iti Atv/aG A.'_C. Z5l//Z
'Physical Address,City,and Zip fL rt. j ;N J I )p Y
/,/rllor^ oy-An'10y6 G 21.REMARKS
County Parcel Identification No.(PIN) D' , 7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,ieeld,one lat/long is sufficient) 22.Certification:
[ ) /�� D�, (� 7 t'
thewell(s): OPermanent or ❑Tem ora Signature o/^ ell Contractor Date
6.Is(are) p ry
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 1914 15A NCAC 02C.0100 or i5A 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.
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
C depth below land surface: .5 (R) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(cremate-3l 200'and 2@)100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: V (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing.use"+"
t�11.Borehole diameter: /y7s (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: et-rl 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) o 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
13a.Yield(gpm)ARel f Method of test: f1li •
/13b.Disinfection type: TN Amount: "/4.5