GW1--05230_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:1 eFi/-f'%y 1LGGI J er/6,c t'/n Cradyso 77 14.WATER ZONES
WellFROM TO DESCRIPTION Contractorame
ft. it /a o 3So L/60
t-i&D(2., a. ft.
NC Well Contractor Certification Number
/�/y/ / / 15.OUTER CASING(for multi-cased wells)OR LINER(if a liable)
2 ., fret///5 �t�[/ ?,2 1` / /I `y� FROM ' `TO,Q DIAMETER THICKNESS MATERIAL
Company Name ft 7 O fL (J �8 in. a P( C.
/
^� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: a .9,1, - 003 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County.State,Variance,etc.) ft. ft. in.
t 3.Well Use(check well use): rt. rt. in. -
- Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑_Municipal/Public h, rt. in.
OGeothermal(Heating/Cooling Supply) PSResidential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO ..1 MATERIAL �,MPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. It. i.
❑Monitoring ORecovery ft. rt.
Injection Well:
ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage R• n-
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(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,wlLrock type grain size,etc.)
r� L o ft. a D ft. Re d c
4.Date Well(s)Completed: 7 7 ,2-7Wel1 ID# a Q ft. 1.J Q ft. f t.1 6 J ,?/fie SlaGr
T
Sa.Well Location: L/g ft, vo ft. V(tc.e.. 6 4,-- ---
1P.riCQ'S I-4e,e c y VI q- LILL-ag1( p tL ft.
Facility/OwnerI Name Facility ID#(if applicable)
/ ft. R.
/ r J �d�.t/i1/t.�L Fa/t/� LA/. ft. ft.
P ical Address.City,and Zip ft. ft.
1're©. L/ / 21.REMARKS
County L 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:
.35. 6y4a8 N Bo. 4Ze7 a4-5 W 7 -a-2-a.z71
6.Is(are)the well(s): ermanent or OTemporary of ed Well Contractor Date
By signing this form,I hereby cert f v that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ICNo 15A 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 remarks 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: 5 D D (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3000'and 2@100')
' L7 D 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: (j 'y (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RD 7a11 I j 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
c Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) -J Method of test: t r
13b.Disinfection type: 7-61 Amount: 3 , Y1 fS