GW1--05211_Well Construction - GW1_20240903

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1 Wel Contra for In o ation:
�,[ 5 14.WATER ZONES
W t FRO, TO DESCRIPTION
Well Contractor Name ! ,ft. (.4 C t.
GI a . l lJft.
NC Well Contractor emfication(Number ( (� 15.OUTER CASING(for multi-casrd wells)OR LINER(if applicable)
` t { S [ \ y r .�s f FROM Tlsi.._w DIAMETER THIC]��y(��SSS MATERIAL
\WI 4 11 1 �J Q ft. ,�I►�- ft. /,l'3 in. Y'I O 0 yV
C2.Wellny Name L 111iG
`()v`\J 16.INNER CAornGOR TUBING(geothermal closed-loop)
2. Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable welt consltitction permits(ha,WC,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 ❑Municipal/Public ft. rt. in.
❑Geothermal(Beating/Cooling Supply) Xesidential Water Supply(single) n. ft. In.
Olndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
0 Irrigation ❑Wells>100,000 GPD FRO TO TERIAL EMPLACEMENT MET &AMOUNT
Non-Water Supply Well: ft. C It. r` h t f,OLLr-e HD❑Monitoring ❑Recovery ft. ft
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 ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTraccr 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO oescs.irrlotN(color.hardneas,soil/tech type.grails sfu,etc.)
❑Geothermal(Heating/Cooling Return)tuf ❑Other(explain under#21 Remarks) O fL I t t,.'ft.
4.Date Well(s)Completed:5'•C.P-, LI Well ID# L n ft- ,..4 5 ft. ii1 t_i_c, n( ' �
5a.Well oc t+v) »^ 1
ation: .,-. �� ft- iO Co ft. k. t
&Zi4e,.... -
.n_e__Q._,
�l ft ft.
sell ty/Owner Name l , Facility ID#(if applicable) ft. ft.
G ft
�P-tire ft.R. ft. -
4C
Ph ical Address.City,and Zip r� r ^
Li(`I� r L Y1 1 21.REMARKS
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iongis sufficient) 22.Cer fi ' n:
. 5 a3-� i N ?76 t-71 W �- a 4
6.Is(are)the welt(s); [Permanent or OTemporary Si azure Certified Wel Contractor 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 orOf3o_d 15A NCAC 02C.0100 or IBA NC4C I12C.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 an 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 I 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 INS I RUCTIONS
9.Total well depth below land surface: (COO
O (ft.) 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')
of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top0 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
If water level is above casing,use
1i.Borehole diameter: l� i/K (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(MC)
12.Well lion method: 60 I9 Program,1636 MSC,Raleigh,NC 27699-1636
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger •lo,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) LA Method of test: Af Permit Program,1611 MSC.Raleigh,NC 27699-1611
13b.Disinfection type: v Amount: /