GW1--04243_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-I,) For Internal Use Only:
1.Well Contractor I rmation:
V) CL I >/l GG 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft.
NC Well Contractor Certification Number R CASING for multi-cased welsORL
ETE TH a UcMaAbl e
FROM DIAMZ#IW//s loyl�l J��l �•�Sl R C�� rL 6 A in. ,Z-50
/C J : L/G Company Name
(� z 16.INNER CASING OR TUBING eothermal closed-lo
2.Well Construction Permit#: 2, 7 �J FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. -j(O R. in, Z fC) U�
3.Well Use(check well use): rL R In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZ.E I TMCWNESS I MATERIAL
❑Agricultural ❑M��unicipaVPublic ft. rt. in.
❑Geothermal(Heating/Cooling Supply) 111Kesidential Water Supply(single) fL ft. ia. -4
❑industriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO TERIAL EMP ENT MEMOD&AMOUNT
Non-Water Supply Weil: O ft. Z,O R
❑Monitoring ❑Recovery tw R•
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. R.
❑Aquifer Storage and Recovery ❑S8lintty Battier 19.SAND/GRAVEL PACK if a tlicabieFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. R
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,bardness,soiltrock a in size,etc.)
V
1 0 rt. 5- rt.
4.Date Well(s)Completed: -z'`7 Well ID# j rt ft. I IoLi G
5a.Well Location: 7 R• SvfL
50 ft-
Facility/Owner Name Facility ID#(if applicable) R R
66 zo .zt c%y ,, fL
Physical Address,City,and 21K
fL h. •L.. ' i.i
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one tat/long is sufficient) / � 22.Certification: � O /� / C
31i! 5i//9��0� N Sd. 6 27 9C W e!�/r , -/ - �7
6.Is(are)the well(s): lar6tnanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform.I hereby cert fv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 2f4o 15.4 NCAC 02C.0100 or ISA 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 ivell owner.
repair under#21 remarks 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 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7✓ (ft.
For multiple wells list all depths fdgerent(erample-3Q20/0'and 2@100� ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
/fwater level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Welts. Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter:_ (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a-i-/ 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 installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /d Method of test: )y Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: Jr17 l