GW1--04260_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
z - lc„„, le?Ge 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
/6 R' 2 ZO ft.
ZU3 33Q ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi{ased yells OR LINER(If applicablc
FROM TO DIAMETER THICKNESS MATERIAL
a VG
Company Name
t' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: .��/7 Z 6 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consm!c6on permits ri.e.U1C,County,State, Variance,etc.) ft. R. in.
3.Well Use(check well use): tt. fG in.
Water Supply Well: 0.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural dMunicipai/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Qi sidential Water Supply(single) ft. R. In.
❑lndustriaVCommerciat ❑Residential Water Supply(shared) 18.GROUT
❑iri ation ❑Wells>100,000 GPD FROM TO D 1ERIAL EMPLACEMENT METiiOD&AMOUNT
Non-Water Supply Well: ft. 46 ft Ak
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑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. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock e,train size.erc)
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks) tt. ft.
`may G C Ct
4.Date Weli(s)Completed: 1 b� Well ID# ft go `t.
VI
Sa.Well Location:/ ;x� ft. ft. t f U'e l
/�icll4iey(A 1Ji�s .S✓ rL �Ofc,
Facility/Owner Name 4/Facility JJD#(ifapplicable) ft. ft• i
Te9 3 Z �/t Ja,r+G /�• Ile IL
ft. - I:I
Physical Address,City,and Zip �) rt. ft. 1 U L 1 5 2024
'/ i7 ✓i� �� / Z J' lid 21.REMARKS -
County �� Parcel Identification No.(PIN) J
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N c� W �,eg
-/ -z
6.Is(are)the well(s): G;lKermanent or ❑Temporary Signature of Certified Well Co tractor Date
Dv signing thisfor m.[hereby cert�that the well(s)a'as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l 111. ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair•fill out knonvr well construction in formation and explain the nature of the of this record has been provided to the well owner.
repair under#21 renran(:s section or on the back oJ'this form.
23.5ite 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 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: 3 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if ififferont(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: 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-16)7
if water level is above casing.use
6' (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Z�;� 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 producine over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /d Method of test:
13b.Disinfection type: Amount: .t 3