GW1--05220_Well Construction - GW1_20240903

WILL LAVA'KUI IIUN KLt'C:UKU(L W-1) For Internal Use Only: '
1.Wei Contractor Information:. .
NO MU lI IS 'firir1 tr) PCQ 14,WATER ZONES
Well Contractor Name J FROM TO DESCRIPTION
G ft. q5 ft.
ft. ft.
NC Well Contractor Certification Number 11 �(I/�� 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
D L rii\. tS v\l'a Ui 11'1 `(' FROM TO DIAMETER THICKNESS MA RIAL�
t ft 2O ft („(tin. U
I
Company Name VL V h i)
(en Li r r7 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: `t J l(1 f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction per?nhs(i.e. IC,County.State,Variance,etc.) rt it in.
f 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 ft. in.
OGeothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEME METHOD&AMOUNT
Non-Water Supply Well: D ft. v`r1 O ft. jr l if POLY
1 tf
❑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, DStormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DES RIPTION(rater.hardness,sotUrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R.0 .30 ft.
~
4.Date Well(s) K )0la4
Completed: Well ID# 30 IL SO ft �� ��,11,e 11
5a.Well Location: _ :a
00 ft' 7O ft. .% r/4+4G/c.xk�7L •
31fArl
Facility/Owner Name Facility 1D#(if applicable) ft. ft. -
Physicalrl At()\41 Oar4ovicp-1- Rd .1,01") ft. ft. " - "
M Address,City,and Zip
ft. ft.
Countyt 'bA�u Parcel t'�la71tion ao. p3 21.REMARKS i .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one lat/long is sufficient) 22.Certification:
36.3r1r119 V N - Vo .61041 I w -, �,�� -t2C
6.Is are)the well(s): ermanent or ['Temporaryatu ertt8ed well onnactor Date
( �
J� 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 tNo !SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information an&`explain the nature of the of this record has been provided to the well owner.
, repair under#21 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: f If o (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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: `,� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: �� /Q (in.)of 24b.For Infection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: `o 1J 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
m 1Al
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) COO ^�' Method of test:
13b.Disinfection type: H ( I Amount: ) Q l S