GW1--03440_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor InfoT
ttion:
/ei1/Jv" le/ /1✓/ot.r.Ac,e... 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Z036 /0 5 R• jsv ft.
f7 V ft. ft.
NC Well
Contractor Cettifica[ion Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Ilcable)
i i 6-5 Wei/ d/l isd -' FROM TO f M�ft. ! � ft. DIAMETER
/ E E In.
THICKNESS MATER`IA/L
4
Company Name l l0/Q 5 ��V
_/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �� 3o FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft. ft. in.
0 Geothermal(Heating/Cooling Supply) 1DDRitsidential Water Supply(single) R. ft, in.
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
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.
DExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DEse PTl Ni(color,h.raness soil/rack type,grate. ate)
u d ft. 3 ft. C
4.Date Well(s)Completed: �J�'Z7 Well ID# ..3. ft. /0 / R. 6
y705
tt✓+i
5a.Well Location: / ... i/QI ft. �v R. //
/��
j - ,IGfG,'s /10 ft Z( 7 IL Xid $/
Facility/Owner Ne Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip n ft.
'/ 21.REMARKS /'.'1'y 7 1 )o i p
/4,or 03 - /59-o3ZG , l)
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D'I. 3 l
(if well field,one Iat/long is sufficient) 22.Certification:
34/, SS305Zo N do, ei/9 Z W .11._ -/ -Zv
6.Is(are)the well(s): fJLP'ermanent or OTemporary
Signature of Certified 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 ItiKo iSA NCAC 02C.0100 or 15A NCIC 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#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 depth below land surface: WO (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if-different(example-3®200'and 2®100')
t 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
limier level is above casing.use"+'•
l I.Borehole diameter: (p/mod (in.) 24b.For Infection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: v 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
�L Permit Program,1611 MSC,Raleigh,NC 27699-1611
'T 13a.Yield(gpm) 0/ '/ Method of test: J✓
13b.Disinfection type: i/l Amount: 3,4 1-5