GW1--03675_Well Construction - GW1_20240618

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WELL CONSTRUCTION RECORD GW 1 h t ht "t t
For Internal Use Only:
1.Well Contractor Information: / l
ter S;try �4`i,ceC`6 14.WATER ZONES
Well ntractor Name FROM TO DES(: ON
, Cs? a - Q 3/i)ft. 3C� ft. , � ,41
NC Well Contractor Certification Number ft ft.
C \` / J 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
�(7 Loat 0f 2d i fh i�. _Liti( t /C FROM TO DIAMETER...„ THICKNESS MATEE/RIIAL.
Corn Name ^ jr l ll��L L
ft. /)Qrft. '��n. 51 i�. -pY<,
!/14"-)
.�3 /9/3`j NER CASING ORTUBINCLigeothermal dosed-loop)
2.Well Construction Permit#: L W ccc777��� CC//VV (,, t 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): ft. ft. is
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QMu ipaLPublic ft ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
R. ft. In.
Industrial/Commercial 0 Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V/.,1 ft.
�5
Monitoring QRecovery R. ft. �1(� !nC }�� I u�
Injection Well:
Aquifer Recharge QGroundwater Remediation ft. ft.
Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMElitOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
8Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) QRemarks)Other(explain under#21 FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
S ` � L/ 0 ft. /01 U ft. ,ire CIS
4.Date Well(s)Completed: Well iD# r_ c ft. R.
5a.Well Location: i� g'0 ft. i ft. 6
j_ .(// / / li 07/ w 1_i f'ft. 3 6-, fL 4 r-..a.-t-e- %r`�'
Facility/Owner Name Facility 1D#(if applicable) ft. ft. ' -
l 1//Y/17��/1� C ft. ft. tr.".:L.: /
Physical Address,City,and Zip ft. ft. J U N 1 8 2024
`Ace/1st - 3 ? y/�F/ 21.REMARKS
/ iii///��� ! Iris:7..hA•�z P -s,a ,T Ur
County Parcel Identification No.(PiN) D A'{`,,'s,y2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/Glong is sufficient) G 22.Certification. r> 1 - �l _ �n
,Sbo?(7 f .7 N r/ // P 0 " w oL l! �C� \ --2 C
6.Is(are)the well(s)0Permanent or QTemporary ofCeRificd Weil Contractor Date
777CCC By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or Ip with ISA NCAC 02C.0100 or 15A 1/CAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may zlso attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 (p (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00')
construction to the following:
10.Static water level below top of casing: 7 5- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: r 7 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction methodct..\L.) above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /S Method of test: C)E'er j(e r,(;t 24c.For Water Supply& Injection Wells: In addition to sending the form to
e` 7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typ st Amount: J C L completion of well construction to the county health department of the county
where constructed.
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