GW1--04559_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r
Ir; c Sa n ci e r s o r` 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
,r ft. 3 O ft.
2 '18 Q• ft. ft.
NC Well Contractor Certification Number /� i5.OUTER CASING(for multi-cased wells)OR LiNER(if ap cable)
Sian d arsons Well Dr 71 /i 4 FR ft 5 ft.
i �7R in. THIC�4c, MATERIAL
ke
Company Name ✓ S /�Jf)/J Y
�y�D y 2 16.INNER CASING OR TUBINGgeothermal closed-loop)
2.Well Construction Permit#: 37FROM TO DIAMETER THICKNESS_ MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS[ MATERIAL
Agricultural 101 cipal/Public 2,5 ft. 30 ft. r yr in. /2 SCir ° Pi<
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft. ` in.
Industrial/Commercial DResidential Water Supply(shared)
IS.GROUT
Irrigation FROM TO MATE L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. 2 0 ft. �7 G Ia••it,/4•t,,
Monitoring ORecovery ft. ft. �Y
injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(it applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. 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,hardness,soil/rock type•grain size,etc.)
Q fL $ Yell�rA, C/d y Sit"c(
4.Date Well(s)Completed: �/��� Well ID# $ ft' IS. ft. Oraie Clay �5tAd
5a.Well Location: // l S ft. 5ft. " &ra li. i/Rn1/57 r�/
�Ilfson 1Y1., ock1C4r 1S 30 WAi ke Coarse SANO.
acility/Owner Name Facility ID#(if applicable) ;
/9/ Do wry Rd., Roo/kind, ,2 F3 83 ,�
Physical Address.City.and Zip ft ft. Jk 1' 3 1 C v`
Robeson 0113-off �io¢ .
w 21.REMARKS Y
County Parcel identification No.(PIN) �''•:'"'`, `, ,
L3'i•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/loonng is sufficient) Q Q r
22.Certification: //+ / / �J 22
6.Is(are)the well(s) manent or Temporary Per Signature of Certified Well Contractor Dat♦e /
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or 135Ir with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under h21 remarks section or on the back of 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: 3O (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
Q I
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: S (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rail
. ( above, also submit one copy of this form within 30 days of completion of well
D` �i construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I'-u� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) . Method of test: 1 14Vid /4‘.'91 24c.For Water Supply&Injection Wells: in addition to sending the form to
N rig the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: ^Amount: _ g r/�A'1 completion of well construction to the county health department of the county
•
f J
t