GW1--05212_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
\re FF(v riezAirr,...76.4.vi ll ja...citscril 14.WATER ZONES
Well Contractor N c FROM TO DESCRIPTION
1/40 D 02 ft. rt. 5 5 /a 5- 3 15 3 a v
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING(for multi-cased wells)OR LINER Of ap licable)
V. L, m /rs toe/l Vr;L1; z FROM i TO DAMETER i THICKNESS MATERIAL
Company Name yn/ H. eq g ft. in.
// 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: D1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consnhtction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
DAgricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IkIrsidential Water Supply(single)
-
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
-
❑lrri ation
S ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEIIIENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a d ft. pa-,.....0„,/
[Monitoring ❑Recovery R. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(applicable)
FROM TO MATERIAL EM PLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rack type araln size,etc.)
O ft. 3 d ft. 2p�J
4.Date Well(s)Completed:41-a 9-c72 yell ID# 3 U ft. Li S ft. s
d►v(.Stto n,. / &, . 5c0Z.
5 i.We l Location: 18 n• Lid
t - e /j
fli. r ebh _ -�- ft. ft. C
Facility/Owner Name Facility 1Db(if applicable) ft. ft.
«4C4 VR ft. ft.
•Ply' al Address,City,and Zi ft. ft.
}. l/ w7 /N.,, 21.REMARKS
anty Parcel Identification No.(PIN)
5b.Latitude an ongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
3 5 Q 3 oga11 N 17 9 , 'f/16_3 W q
6.Is are the wells: S rti6ed Wellctor �"� ` _ I�
Is(are) Omanent or ❑TemporaryDate
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or At 15A NCAC 02C.0100 or 15A 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 remark,section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks B)xj.You may also attach additional pages if necessary.
drilled: d
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d 0 (ft)
For multiple wells list all depths ifdierent(example-3 200'and 2 tt 100`) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 5 (ft) 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
11.Borehole diameter: ' /' (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well Construction method: / O?Lary(i
(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:
� 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA13a.Yield(gpm) _5 Method of test: 19 / j^ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H T Amount: 3 /1 fS