GW1--04240_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,Well Contractor Information:
SeFFr,e y ��Clj F'I' 6.t yr'n J d C/fS D/) 14.WATER ZONES
FROM fL TO DESCRIPTION
Well Contractor N e
44&o ft. ,5s- t-5 0 qD o
/ o
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER If a llcable
�• /�[.���/ S We V ri I��l•n!y �A/C. FROM TO DIAMETER THICKNESS MATERIAL
Company Name �/ -t--I ft. LJ
I fL I
& / in. I , a 5 10kI C_
h� 16.INNER CASING OR TUBING thersosI closed-loo
2.Well Construction Pe t#: FROM To I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG Coun(V,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL 1114 in.
❑Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. fL
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Im ation• ❑Wells>100,000GPD FROM I TO gM�ATERiAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: IL a U ft. ,U t�o✓lq�
OMonitoring ORecovery fL It.
Injection Well:
ft. I.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft. M
OExperimental Technology 0Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets If necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) mom TO DESCRIPTION(Color,hudn sewrocx is sine,eta
). i sL/ It. 1 ft. �.JA e` 7�/) e
4.Date Well(s)Completed:_ `1 _ Well ID# IL ,yfL L
5a. ell Lo ation: 44 o i
ft. R.
a ility/OAiner Name Facility ID#(ifapplicable) ft. R.
(o3 /q rfw�� ao5 fL fL. '
Physical Address,City,an Zip 21
L/r� ft ft
�11 / O t) 01/ .REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) r_ / 22.Certilieatiorf:
13 l J N 1 3�9 g l 2W c2 y
6.Is(are)the well(s): Ufflle-rmauent or OTemporary 1i64na*q0KfC&Med Well Contractor Date
By signing this form,I hereby cert4N that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &NO 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 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 miner.
repair under#21 remarks section or on the back of 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 1 GW-1 is needed. Ir dicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: C-) _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacs:- C;�0 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiiferent(e rample-3Q200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of cas ng: 30 (fL) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing.use
11.Borehole diameter:
(o �fj -(in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(JUC)
1 Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: _90-ke r y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where insta e
FOR WATER SUPPLY WELLS ON LY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
/J{ D Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: �f r
13b.Disinfection type:tj 714 Amount: 3 -k.S