GW1--04238_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.W ll Contra or Info tion:
l Wk U C l�<J 14.WATER ZONES
11.. FROM TO DESCRIPTION
Well Contractor Name
ft. fL
NC Well Contractor Certification Number ( IS.OUTER CASING for multi-cased wells OR LINER f a livable
<. FROM TO DIA 1E R THICKNESS :MATERIAL
l Company Name
—� � 16.INNER CASING OR TUBINGgeothermal closed-lot
2.Well Construction Permit#: 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): It. It.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER I SI.OTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) (L L in.
dustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irn ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN7
Non-Water Supply Well: ft. %
❑Monitoring ❑Recovery ft. ft.
Injection Weth
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 11 ❑Stormwater Drainage ft. ft.
❑Experimental Technology []Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM To DFsc3tlPno
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) eobr,b,rda wiurvex L,:ize ere
rt. ft.
4.Date Well(s)Completed: � Well ID#e. � fL ft
5a.Well Location: .`� �"�C"
IL
ft-
Facility/Owner N e Facility ID#(if applicable)
It. R
P ysical Address,City,aa Zip (�,/
03 �"\�1 03 I 23.REMARKS _
�J h t t�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wel field,one tattlongis sufficient) ( ( (^ 22.Certification: `� • t._
N �O `T as `f' W
6.Is(are)the well(s): ❑Permanent or ❑Temporary 'gignaTure of Certitie8 Well Contractor Date
By signing this form,I hereby certifv that the wells)xns(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 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%wit owner.
repair under#21 remark section or on the back oJ'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 I 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: ��qC)
(ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@1001
24s. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: c=�� (t) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: f (in.) 24b.For Injection Wells. Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Weliflonsuquetion method: 24c.For Water Supp I and Open-Loop Geothermal Return Wells:Copy to the
rota(i.e.auge ry ble,direct push,etc.) 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
r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
T Amount:
13b.Disinfection type: