GW1--04245_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
l�l✓a'✓x A/� / /,a><' g", 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ZC33�
ft. Ho-
1O IL
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NC Well Contractor Certification Number C7
IS.OUTER CARS for multi cased wells OR LINER f a licable
FROM Dtl//If t��it I !A/ /! L O ft. ETERin.
Tttt�L�CKNESS MATERIAL
Company Name • 7 Gi
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: r/60 FROM To DIAMETER I THICKNESS I MATERIAL
Cut all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): fL I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic fL R. in,
❑Geothermal(Heating/Cooling Supply) GWesidential Water Supply(single) ft fL in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. W ft. Apt L /.
❑Monitoring ❑Recovery rL rL T
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicableFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessa
❑Geothermal(Heating/Cooling Return) TO DESCRIPTION color,hardness,sotYrock in size,eta) ❑Other{explain under#21 Remarks) ft ft.
C
4.Date Well(s)Completed: 7�f���y Well ID# O fL a S 1-
5a.Well Location:: Q 2 S �ft' Z ft
io
04A U-GSGl/�.Jl ;' 3'2 fL d
Facility/0 It
Name D, Facility y�h• , f t(�(✓
n f� we
/ S Q��
-��-_47 BCD/ fL fL
/r!C
Pbysical Address,City,and Zip fL ft.
1-0 l{c C 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
%3V!!�/9 N /1 yip. W
6.Is(are)the well(s): liAvermanent or ❑Temporary Signature oTCertified Well Contracior 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 too ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
#'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 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 we]]construction info
construction,only I GW-I 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: /a� (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdtfferenr(example-3Q200'and 2@1001
( � 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11.Borehole diameter: y"� (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) tocounty 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: HI
�>/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: / f