GW1--03928_Well Construction - GW1_20240705

•
WELL CONSTRUCTION RECO (GW-1) For Internal Use Only:
1.Well Contrite r. foorrmation: ,
�aL. 14.WATER ZONES
Well Contractor N FROM TO DESCRIPTION
;J �J /) / ft. 3 2.D ft.
/ 7 // ft ft
NC Well Contractor Certification Number
15.OUTER CASING(for multi-used wells)OR LINER(lisp Gable)
�'�-A-,},-m J 13 rc�-t-�-, -e_v FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO _ DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIG County,State, VoNonce,etc.) -1- ' ft. )0`) ft S 14/
/ in. ri l d`, P✓v
3.Well Use(check well use): ft. n O ! /
Water Supply Well: 417.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERL
❑Agricultural ❑Municipal/Public ft. _ ft. in.
❑Geothermal(Heating/Cooling Supply) Fsidential Water Supply(single) ft ft In.
❑Industrial/Commercial ❑Residential Water Supply(shared) lg.GROUT
❑IlTigation ❑Wells>100,000GPD FROM TO TEAIAL EMPIACEMENf METHOD BAMO
Non-Water Supply Well: () ft. Z� ft De&
p n 4.4
❑Monitoring ❑Recovery ►/ ft ft. ���KKK{ "t
Injection Well: yVY t 11G1�►✓C n
ft. tt ( l
❑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. R.
• ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION{Teter,haraeesa soil/rack type train the,etc
ft R.
4.Date Well(s)Completed: Y -z y Well ID# ft ft l 1. `I Ni 1
ft. ft. �1�� to24 Sa.Well Location: t
rc rf 1- D 2v; s ft. R. WK.'-i.'t
• Facility/Omer Name Facility IDN(if applicable) rt. ft 1/t•`�it�i
wn
.S .-kr , Z Z� -- 9 3 , Sryl /t h-c, /Pal. ft ft
P icel Address,City,and Zip , R. ft
As/4, 21.REMARKS,/
CounntyParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer • • n:
_ sz:4711:44........
3G' /tl' 3L N / " 3/ ' sl ' W
6.Ware)the well(s): Permanent or ❑Temporary 3 1 1J Signature of ie ell Contractor Date
By signing this form, hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or 1No 1SANCAC 02C:0100 or'13,Y NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,fill out known well construction information explain the nature ojthe of this record has been provided to the well owner.
repair under N2I remarks 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 in
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Over'in RtSrrarl�Box).You may also attach additional pages if recess
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
3
a 24.SUBMITTAL INS 11LUCTIONS '
9.Total well depth below land surface: (ft.)
For multiple wells list all depths if different(example-3@200'and 2@l00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: SC (fL) 24a. For All Wells: Original form to Division of Water Resources (DIA
If water level is above cosing,.use^+^/ r/�J Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: lJ / b (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(II
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) a r r�i 1 r 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to
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,CCPC
13a.Yield(gpm) ) 5 Method of test: Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: f 1 14 Amount: g f.Y