GW1--04244_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well�C,ontractgr Information:
_ i1-01✓t /1 z////a✓1 i 14.WATER ZONES Well Contractor Name FROM TO DESCRIPTION
Z-13t. ft.
!d345* ft. ft,
NC Well ContractorCertification Numbbeer, 15.OUTER CASING for mulfltased wells OR LINGER a livable
�C� . /!/L IG//�/!• �V�I U✓//�IA� FRObf ft �� fL � tETER In. THZ7 0 MA
Company Name
16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: --,y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.U1C, ountx State,Variance,etc.) © ft• Z//ft. y!i on. 0 vG
3.Well Use(check well use): It. e7 f. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) G esidential Water Supply(single) fL ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft zZ o ft. GM T
❑Monitoring ❑Recovery ft R
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
OExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color.hardness,sowrock e, rain size,eta.)
4 ft. #0 rt C ft
4.Date Well(s)Completed: 6 -6 Z-1 Well ID# -,1 o fL 9, ft sq N en, C &
Sa.Well Location: �% f1. /G0
�b✓L- ids fL 2z5ft- ket Ie
Facility/Owner Name �FFacility ID#(if applicable) Z *500 IL
Saw L✓aX�t;;.1A) Ayy/vt / V IJaCnj, .ra fL ft.
Physical Address,City,and Zip Q ft. ft.
Zl 1Oil �g�r/3G 'Uzo 21.REMARKS
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneettat/long is sufficient) 22.Certification:
C/
�1r7_L7� N �3 O e //�5 /G//J41? W 6 -�`z' /(�
6.Is(are)the well(s): WIfermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V40 ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out knotwt well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the stone 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: -3W10 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3©200'and 2@1001
L 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above casing,use"+"
// 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: t'a YD (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: -C✓'7� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) U 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) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
CsV /✓L
13b.Disinfection type: A/ry Amount: