GW1--04237_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
t
u 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
fL ft.
A o 3 ll ft. ft.
NC Well Contractor Certification Num r 15.OUTER CASING for multi-cased wells OR LINER rf a likable
r-1-1 mu THICKN
TO DIAMETER ESS MATERIAL
ft ft ( in.
Company Name 16.1NNER CASING OR TUBING(Peotherma{closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well constriction perndts(i.e.UIG Counts.Stale,Vanance,etc.) ft. It is
3.Well Use(check well use): rL rL. in.
Y Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER I SLOTSIZE ITHICKNESS MATERIAL
❑Agricultural _❑Municipal/Public ft. iL
❑Geothermal(Heating/Cooling Supply) ➢gResidential Water Supply(single) ft. rL
❑Industrial/Commercial '❑`Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMO[)NT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ff applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL PLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage n• tL
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG fattach additional sheets If necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEscwPTION(rotor.harau eolLroeh to dze etn)
it.
ft.
4.Date Well(s)Completed• ,+ Well ID# rt ft'
S,a. ell Location: ( tt. it CLt
t
ou-S c�- ft. ft.
Fact ity/Owner 4e FV-IRA, acility ID#(if applicable) IL R,
ft. ft.
I Address,City,and Zip ft. ft.
�+ 21.REMARKS
�Kf-2,
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
'36 .q ail c65 N Y .C: ag a
6.Is(are)the weli(s): Aermanent or ❑Temporary Signature of certifiedWell Contractor Date
By signing this form.l herebv certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if r,this is a repai fill out known well construction information and explain the nature of the of this record has been provided to the xrtl mvner.
repair under#21 remarky section or on the back oJ'dris 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: -.2 .i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wails list aU depths ifdii ferent(example-3 a 00'and 2@1001
t 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: _ S (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJtvater level is above casing.use"+"
( i 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: I ID
�r� (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: MAC �� 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 mstalled
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)�.�_ Method of test:,� �
13b.Disinfection type: f Amount: