GW1--05178_Well Construction - GW1_20240830

WELL CONSTRUCTION RECO (GW-1) For Internal Use Only:
1.Wel m
' � ctor•Inforation• •
.
•
..V • •14.WATER ZONES
Well Contrfct `/�'.� PROM TO DESCRIPTION
ft. ft
NC Well Contractor Certification Number
,-, _ 15.OUTER CASING for mull-wed wells OR LINER(if a liable)
Wit/I 1 rU -e_V S PROM - TO It. ft. DIAMETER THICKNESS MATERIAL -
Company Name
in.
/ /„ S/ ' 16.INNER CASING OR TUBING(geothermal dosed-loop) •
2.Well Construction Permit#: { C!/ O PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe veils(l.e. County,Stale,Variance,sic) - l R S5 fG. 5 ,l id
�J�j %!`�L pre:-
3.Well Use(check well use): •
2 R in
Water Supply Well: j7.SCREEN _
• OA Cultural PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Hn .OMtasicipel/Public ft. R in.
°Geothermal(Heating/Cooling Supply) C sidential Water Supply(single)
/a ft 2 im.'
❑Industrial/Commercial °Residential Water Supply(shared) -
I0.GROUT
°Irrigation OWells>100,000GPD PROM TO - I MA EMPLACEMENT METHOD&AMOIRIT
❑Non-Water
r Supply Well: 0 2 50 R Ati G t4./1 i ;L `!
• uY R R �f•�
Injection Well: ORecov D D 1a i 1 CA..12 � .`
•
oA uiferRecher n' D• `
9 Recharge °Groundwater Remediatjon
°Aquifer Storage and Recovery °Salmi Barrier - �•SAND/GRAVLLP.4CTC(ifappliable)
ty FROM TO MATERIAL EMPLACEMITIT METHOD
OAquifer Test OStormwater Drainage 2 tt.
°Experimental Technology °Subsidence Control ft. is-..
• °Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Iieating&Cooling Return) °Other(explain under#21 Remarks) PROM TO DESCRIPTION Osier,hardness walncle eype she,etc)
�j ft. 2
4.Date Well(s)Completed: O "2 7-2-1- Well ID# • 2 2 A/t • _( n • o i
sa�well Location: ft 2 ^ r.Q�t
• ,ir 1 0 rdvi 2 ft J, •
• ty/Onuer Name f FacilityIDE(if applicable) R ft. r, V a,r i_an e-Le
&Yeeyn ACr e 5 Es-z 1- 1 A r t. .,.R ft. wv . J�►.6 3 set 7
Physical Address,City,and Zip ft.
ft.
a 21.REMARKS./
County Parcel Identification No.(PIN) • , e/ J 2.61 .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
gyre!!field,one laf/bng u sufficient)
-
22.Ccrtifica
36.1 13' 5191 N / ' 3,i- ' 32/ �
W t
f
6.Is(are)the well(s):Yrermaneut, ora or °Ten Signatrue ofC (*Mel],Cnntractor Date
p r 1 2-7� ' By signing this foam,I here! 'err t:.:t the N_li)war here constructed In accordance with
7.Is this a repair to as existing well: °Yea or INo 13,4 hCAC 02C:0100 or']A NC AC 02C.0200tWell Construction;tau is a repair,jell old blown well toms action information explain the nature ojlhe of dal record has been prodded to the well owner. prutrtrcdon S/andards and that a copy
'repair under 121 remarks tectton 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 sense 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'Sec Over'in Rena ics Box).You may also attach additional pages if neePee,ry.
drilled:
• /' /� t 24.SUBMITTAL INS[TBUCTIONS
9.Total well depth below land surface: 2� (ft)
For multiple wells Uri all depths ifdierent(example-3@200'and WOO') Submit this OW-1 within 30 days of well completion per the following.
10.Static water level below top of casing: / 60 ' eft) 24a. For Al! Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,sue'+ •
'/ Information Processing'Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (rV/ kin.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC
6 f .r(� • _ Air Program,1636 MSC,%sleigh,NC 27699-1636 )
12.Welt construction method: [
(i.e.auger,rotary,cable,died push,etc.) 24c.For Water and Open-Loop geothermal Return Wells:Copy to the
•
county environmental Supplyealth department of the countywhere installed
FOR WATER SUPPLY WELLS ONLY: . •
24d.For Water Wells producing over 100,000 GPI:Copy to DWR,CCPCUA
13a.Yield(gpm) 15 Method of test: . Air • Permit Program,1611 MSC,Raleigh,NC 27699-1611
1.4. 11
13b.Disinfection type: � / Amonuf: r � is/
T.....mar .