GW1--04236_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,Well Contractor I formation:
I„t I/Ja,,t a 14.WATER ZONES
FROM TO DESCRIPTION
Waif Contractor Name
R.
- 4 R. l
NC Well Contractor Certification NumberL 15.OUE formulti-cased r O a Ikable
FROM CO DAMETE MATFMAAL
✓! /t �ft. ft 6 Xf in. Zfr0 UV
Company Name
f �/ 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: .`v'7 ` FROM To I DIAMETER TIUCKNM MATERIAL
List ail applicable well constntction permits(i.e.UIC,County.State,Variance,etc.) ft. it in.
3.Well Use(check well use): ft. r, In
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE TMCI44ESS MATERIAL
❑Agricultural C]Municipal/Public R. R. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. fL in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
DIrrigation OWells>100 000 GP IA
D FROM TO MATERL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft' ft-
❑Monitoring ORecovery ft. ft.
Injection Well:
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK f applicable)
(]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOII
❑Aquifer Test OStolmwater Drainage ft. ft.
OExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM I TO DESCRIPTION color.hardness,sollInwk type,gnin size,etc
fL S m C14
4.Date Well(s)Completed: o6 �a—L Well ID# f s ft. ft.
5a.Well Location: i C) ft' D R.
llei fL R.
.tee":
Facility/Owner Name *Facilityll) )(ifapphcable) R' R' -`
'�'.�� ) t,,� .lit ///► (L IL
,
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Physical Address, try,and Zip ft '
O`O�/OOP 21.REMARKS
County Parcel Identification No.(PIN) -
t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, s one tat/long i sufficient) C� 22,Certification:
/
;4v,/,
6.Is(are)the well(s): erinanent or OTemporary Signature of Certified We11 Contractor Date
� By signing this form,I hereby cert�that the wells)was(were)constructed in accordance wfth
7.Is this a repair to an existing well- ❑Yes or *1Vo 1 SA NCAC 02C.0100 or 1 SA 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 oJ'dds form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wails having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I 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
i
9.Total well depth below land surface: "R (R') 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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
tf water Level is above casing.use"+"
// ` 1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: ( I (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: 419 r`y 2 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 tnstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
,n Permit Program,1611 MSC,Raleigh,NC 276 9-1611
13a.Yield(gpm) � Method of test:
13b.Disinfection type: Amount: