GW1--05201_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: i ,
bi is 10!fr _ L SA)1 r+ J QLFSU 1.-114.WATER ZONES
Well Contractor Name J FROM TO DESCRIPTION
y0 ft. ft.
26 j GI A 5 Zon'
NC Well Contractor Certification Number ` - 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
p L.� (\r‘V 1 1 1 1 We. 1 1 1�\Y_, r 1 1 I FROM TO DIAMETER THICKNESS MATERIAL
Company Name V .{- ft. G ft L in. t��9�� `,v
ff,, JJ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: .H(62 ICI - I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. R. in.
3.Well Use(check well use): ft. It, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Ill Agricultural ❑MunicipalPublic ft. IL Ia.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft. la.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL • EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: O ft. 20 ft, Ont
❑Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediatitm -
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test• ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geotherma! FROM TO DESCRIPTION(color,hardness,sowrock type,grain size,etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ." !O ft' irk c lad/
4.Date Well(s)Completed:13 IT?-1 ktkg Well ID# I a ft' VI it r- Al S(Or4e
5a.Well Location: ,-t bR ft. � d /6I , -
"Toc-ckCAn reAI'- r\
Facility/Owner Name t^ Facility ID#(if applicable) ft. ft.
Co.,-,-tJ\ t T car f< ft y
Physical Address,City,and Zip ft. ft.
RkC-Nino► \c- 1410604S 17Z31 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/bng is sufficient) 22.Certifies
3S 5 c I S S'1 N -1 $: 12,3 S 1 w ..... 12,---) I zy
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Con czar 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 *No /SA NCAC 02C.0100 or I SA 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#2)remarla 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: 24.SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: S b 0 (R') Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3 t®200'and 2Q100') y p
10.Static water level below top of casing: 3 S- / (fL) 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
1
11.Borehole diameter: r 8 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
L� , \ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: PP\f- - -0\ry 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
13a.Yield(gpm) CI Method of test: 'N.1 e-.. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: I'# Amount: 1 TVA'