GW1--05219_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: V
1.Well Contractor Information: /4'10-"‘ ‘/C....e., l4.WATER ZONES
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Well Contractor Name FROM TO DESCRIPTION
36 /5D ft. z..gd ft.
ft. ft.
NC Well Contractor CAer/tificati nNtunber 15.OUTER CASING(for multi-cased wells)OR LINER('dap livable)
�// ��/�//,s 1 L j Ia) 8.,,
FROM'L TO DIAMETER THICKNESS MAIRIALCommpapanyCN'ame ltiC� 7L j/�,ft. (�9" ft. ,6" /,�j in. Z>!d �" ` C
i il^ 16.INNER CASINGS OR TUBING j(geothermal closed-loop)
2.Well Construction Permit#: / / 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance.etc.) rt. ft, in.
3.Well Use(check well use): rt. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, it. in.
OGeothermal(Heating/Cooling Supply) Clileesidential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMI` ENT METHOD&AMOUNT
Non-Water Supply Well: D ft' -W ft, A-41oJtpie /Gu.
❑Monitoring ❑Recovery ft. rt.
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 It. ft.
❑Experimental Technology ❑Subsidence 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 DESC ON(color.hardness,saWrock type,grain size.etc.)
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4.Date Well(s)Completed:�'//Z-74Well ID# O ft' /70 ft. c1 /SG s
5a.Well Location: :-ti 70 ft' cf0 ft' •.d S ernc •
ga✓i 1/11e/17- 90 ft. 95-- ft- 6-A-.,.....)
Facility/Owner Name Facility ID#(if applicable) / ft' 3Crer. // .
/oo I 6y-e,e)1 /e✓a'i Cir• ft ft.
Physical Address,City,and Zip [/ ft c
� �i,le4kai5 /qq-3 53 -Li 2 21.REMARKS t P )
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/Z-7 6 -7- 6/. G7 cee9z,9 w ,
// S/' -Z y
6.Is(are)the well(s): Irmanent or ❑Temporary Signature of ertified Well ontractor 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 �Ivo ISA 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 remark 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: 724.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3Gk / (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100')
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
(R) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: ‘ L (in.)
/� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /r n? L "-y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) o 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) .�0 Method of test: Ali
13b.Disinfection type: f7 T/7 Amount: ',/4HTf