GW1--05182_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: !,
TeFf ce`/ /tc.c/fer/GCt.f/i 7aC/4( 0/7 14.WATER ZONES
Well Contractor Na a FROM TO DESCRIPTION
1-1�0 0 ft. It. 73 j /3 o / 75
ft. rt.
NC Well Contractor
Certification Number. // 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
�I L, fruits to e`/ V r /l%n ../vc. FROM TO DIAMETER THICKNESS MATERIAL
.../../ ft. S ft / n
Company Name ! l� !�$ in. •a S / C
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: • IC f) / 1(, 3 C) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.County,State,Variance,etc.) ft. it• itt.
3.Well Use(check well use): ft rt. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipalPublic ft. D. In.
❑Geothenal(Heating/Cooling Supply) 13Residential Water Supply(single) n• ft• in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft a 0 ft. _ pD
❑Monitoring ❑Recovery ft. ft �Ifo7�•� 2sC
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test' OStormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONQ (color.hardneuc wWrock type,grain size ere.)
r� a R. a 0 ft. i e Ci c/u-J
4.Date Well(s)Completed:/-/s.-of1 Well ID# 4) ) ft. L./s ft ‘5.,,/ ..fr),
5 . ell Location: :► L'1I5 ft. 5 7 ft. 2?e...•e 54 -/ �,
57 f- aDoft. 2?L4,c G. G�
Facility/Owner Name Facility ID#(if applicable) f• n•
1l/D37 t i% u ap
6ro
P ] d rt ft.
Physical Address,City,and Zip ft. ft.
/1307_S) )r]
m, G/f Le n 4 r 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. 2Og8S N So• c7`7587 W 7-is -a'--/
6.Is(are)the well(s): 131cmanent or OTemporary S' at Ce 'fled Well Contractor Date
f 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 vivo 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 owner.
, repair under#21 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 construction info
construction,only 1 G.. -1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: CJ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a 00 MO Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'•
/ 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: !� �� (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ro f 6t.r y 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
to t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 10 Method of test: 1 r/ r
13b.Disinfection type: 7T ll TL� Amount: