GW1--05231_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
5C FFre y l t_ /r'er er.//i n .:714-C/1S0,, 1144.OWATER ZONESM DESCRIPTION
Well Contractor Name
yeo ft. i� o> /3S� lLo
ft. ft.
NCB Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap likable)
t//e L, /77 CC / 7 W e l/ ;�i c i/ n Zy C, FRO/nr TO DIAMETER THICKNESS MATERIAL
Company Name ` ft. DIAMETER
QQ (O/$ in. 1 tx 5 tpdC
/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: •'al
O ^3 - �J p� 0 4OQ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C.Counrv,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. ft. in.
` Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) litftre.sidential Water Supply(single) ft ft in . •
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: d ft• c2 0 ft. 234' el, P
❑Monitoring ORecovery rt. 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.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,arain size eta)
0 ft. c, 0 rt. la, •
4.Date Well(s)Completed: 7-/6 7,2%ell ID# 06 ft go ft. e
Sa.Well Location: /0 rt. 10 3 ft. (/,.'gre /lf/OctJ/7 ,SIO�-
Jim lu Son /o$ it .2o0 ft f�e `SG /G•2..,t,`
Facility/Owner Name Facility 1D#(if applicable) ft ft.
/30 2►'reG7L R. me rc5vi 1 IC ft ft.
Physical Address,City,and Zip t ft ft.
.Irtd e I(I 21.REMARKS �� •.
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: •
35, 5-'7 S a-2 N ?o, C1/57 9 W _ `�j--i6-��
6.Is(are)the well(s): ermanent or ❑Temporary tfied ell Contractor )Sate
By signing this form./herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or SK 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 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 l GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 024.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L%1 0 (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 2@100')
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: li !g (In.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: !1 O 7/�r l/ 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 GPO: Copy to DWR,CCPCUA
Li ' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 0 Method of test: ///r
13b.Disinfection type: 1/TN Amount: .3 f/'i') -t-S