GW1--04261_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
G/iJlv1 Ae'& / A�e' W',G'r_ 14.WATER ZONES
Well Contractor Name FROM TO/ DESCRIPTION
C-1J36 D ft. 65 f`• wGe e✓
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ira Ilcable
_ GL[�)s �G l /✓Imo//11.�� FROM TO DIAMETER THICKNESS MAT RIAL
ft / in. Z,! v/
Company Name T � l�
16.INNER CASING OR TUBING eothermal closed-lootil
2.Well Construction Perrpit#: j00136�3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. IL in.
Water Supply Well: 17•SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OM���unicipaUPublic ft. fL In.
OGeothermal(Heating/Cooling Supply) UICesidential Water Supply(single) ft R. In,
0Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft. R.
❑Monitoring ORecovery R ft
Injection Well:
OAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a livable
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology OSubsidence Control ft. I ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(HeatingfCooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,bardness,soWrock rfM grain size,eta)
/} rt. -ZO ft.
7 4.Date Well(s)Completed: V1 We;;ID# ft. fG
ZD n a
Sa.Well Location: ;., ft• 1r0 R G a G
fL R.
Facility/Owner Name Facility ID#(if applicable) ft. R•
f` ft.
Physical Address,City,and Zip ft. R. ` , '
M
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3S ZZAD /su���7 N '90. Jb W
6.Is(are)the well(s): Pf ermanent 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 &Wo 15A 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 well mvner.
repair under#21 rentarAs 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: Q (ft.)
For multiple wells list all depths jdifjerew(erample-3©200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: a r (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing.use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: �g (;n,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
1 Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ✓07a✓`/ 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 producints_over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) G Method of test Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: &7-;41 Amount: w-'/