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GW1--05195_Well Construction - GW1_20240903
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • 1.Well Contractor Information: �j J& l t ii,i 41�1 —/4./ic L" ✓/CZ,. 14.WATER ZONES Well Contractor Name , FROM TO DESCRIPTION 2,03‘ a✓ rt. I go ft. %NCWell Contractor Certification Number) C✓h It. //.li �i 6/I l I // IS.OUTER CASING(for multi-cased wells)OR LINER(if a licable) // /i'r<, '�I ft' ��FROM i TO DIAMETER / RKNE53 rVTq /y Company Name j A CI ft //� in. I/v 2.Well Construction Perlllit iy; L11ry f.JE Z.-oz.-3_ 16.INNER C TO ASING OR TUBBING(geothermal closed-loop) List all applicable well construction penults Re.UIC,County,State.Variance. � DIAMETER THICKNESS MATERIAL it. h. in. 3.Well Use(check well use): ft. ft i Water Supply Well: 17.SCREEN ❑Ag1iCUltUlal FROM TO DIAMETRIC SLOT SIZE THICKNESS MATERIAL ❑Muyicipal/Public ft h. in. ❑Geothermal(Heating/Cooling Supply) deesidential Water Supply(single) h' in. ❑industrial/Commercial ❑Residential Water Supply(shared) ❑irrigation 18.GROUT ❑Wells>100,000 GPD FROM TO MiTERIAL EMPWLVIEN2ETROD&AMOUNT_ Non-Water Supply Well: R. 30 ft ❑Monitoring ORecoveryfeu,/fit dle/t' Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation ft R. ❑Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(If applicable) FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Test ❑StomrwaterDrainage ft. ft. ❑Experimental Technology ❑Subsidence Control ft. ft — ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(snitch additional sheets if necessary) ❑Geothermal(Heating/Cooling Return) pother(explain under#21 Remaiks) FROM TO DESCRIPTION(color,hardness.eoWrocle type,grata sle etc.) © rr. 9 ft' G/a. 4.Date Well(s)Completed: ''/l✓.--Z�Well ID# GJ ft* 3 , ft• � �Ycy. or,G a 5a,Well Location: 30 II. 90 h. I' k� �i'a.s+i�G • Ai)h✓ram Yra/5. e Lae 4-- 90 Sao ' // /1 Facility/Owner N Facility lD#(ifapplicable) R. h. - /0 o 5a.,1., I ye/ ft. ft Physical Address,City,and Zip ft ft r .ai1CL60.tf5 2].REMARICS County Parcel Identification No.(PIN) 5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 55 L�11yy N 22.Certification: go, s�z s30 w � �� -/5-�4/ 6.is(are)the well(s): ill• rmanent or ❑Temporary Signature of Certified Well Contractor Date By signing this form,I hereby cart/that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or 110PIti 1SA 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 esplain 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: j 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: OV (ft) For multiple wells list ail depths If different(=ample-3©200'and 2©100� Submit this GW-1 within 30 days of well completion per the following; t f,) 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: ?j� ( ((wafer level is above casing,use +^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617 11.Borehole diameter: /g (In.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC) /� ) Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: ,�.qYd (i.e auger,rotary,cable,direct push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the county environmental health department of the county where installed FOR WATER SUPPLY WELLS ONLY: A • 24d.For Water Wells producin(;over 100,000 GPD:Copy to DWR,CCPCUA 13a.Yield(gpm) / Z." Method of test: '!,✓ Permit Program,1611 MSC,Raleigh,NC 27699-1611 13b.Disinfection type: tY/ Amount:}�/t res