GW1--04241_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:/
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FROM TO DESCRIPTION
Well Contractor Na
k'l & o t) ft. ft.fL g v 1 O
ft. rt.
yNNC/1 Well Contractor Certification Number / 15.OUTER CASING lti for mu -cased wells OR LINER ifs citable
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el NESS MA RIAL
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Company Name "1 - _21_5 P G
/�Q 16.INNER CASING OR TUBING eothermaI closed-loop)
2.Well Construction Pergrit#: FROM TO DIAMETER I THICKNESS I MATERIAL.
Litt all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. R. in.
3.Well Use(check well use): ft R' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic M @. in.
❑Geothermal(Heating/Cooling Supply) C91t9idential Water Supply(single) M ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft- U tt
❑Monitoring ❑Recovery ft. fL
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK it applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑(Other(ex lain under#21 Remarks) FROM fL ! O R. L TO DESCRIPTION Color,bards���� c l
solllrock in size.etc.)
4.Date Well(s)Completed: �-.f 7- '2-I Well ID# IL
1141 ft' e .5'1" e
Sa.Well Location: '7 , �O d ' KJ��t G iL�'r�'
1> �-). �� u� laa� LL- ft ft
Facility/Owner Name Facility llNi(ifapplicable) ---
(� o5 Av_C, a o 5 fL _ s
Physical Address,City,and Zip ft ft.tz
17 t D n O/ ,t rt I O/rl C 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
3,5, l 3�Y,S ( N go, 3 &3 W
6.Is(are)the well(s): ermanent or ❑Temporary ftafolie.415Certified Well Contractor Date
Av signing this form,I hereby cerdfv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or 01<0 /SA NCAC 02C.0100 or 15A 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 ivell owner.
repair wider#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. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: D 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "/ (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple ivelis list all depths ifdifferent(example-3©200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 35 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if tuater level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
p Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: D AG 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 tnstailed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
/J Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) '"7 Method of test: !7 / )�
13b.Disinfection type: Y 7-11 Amount: 3 t