GW1--05241_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor/nt Information:/
tieF cey ��iGrl er / ,#,
� 4S014.WATER ZONES
Well Contractor N e FROM TO DESCRIPTION
ft. rt. �itj) HO '/TSB ,2 j SS
11" D� ft. ft.
NC Well Contractor Certification Number
/ eY1 J/ 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
�• L• m�!/f LfJPz/ U"ri Gj/17 �/(/c FROM TO DIAMETER THICKKNESS MATERIAL
Company Name I lJ tL�
C i I N_i . `e.-J • ��3 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: H f.� W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in. -
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R it in.
❑Geothermal(Heating/Cooling Supply) ®'Residential 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: O R. O ft. •
^
OMonitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test• ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) FROM 'TO DESCRIPTION(color.boraness soli/rocktype,grain size.etc.)
M ft. 'aO ft Ji j/ RDC/ /��
4.Date Well(s)Completed: Well ID# Q 0 r. hIP 9 ft. ' re)4 - fAP l//l.1Clc.e GAKZ
„......,INa.Well Location: 1', �'`� ,/ �� ft. 3 6�• z�to G�tM�t�
Ail� lel� t' r ` �l�.W�IQ�1►e► fL ft.
Facility/Owner Name U Facility ID#(if applicable) ft. R•
'-100 '7 TG.IC�-Gy yR, ft. it
Physical Address,City,and Zip ft. ft.
�l`t rrU.S 11.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/lonng is sufficient) �r ^ C 22.Certification:
3S, a Ois 1 N � J o, OC,V.s W c7 -
1CQLI
6.Is(are)the well(s): lrmanent or ❑Temporary Si m Cert' Well Contractor Date p
By signing this form,I hereby certify that the well(s)tans(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or SIvo 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2®100')
3S 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: 673 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RDfa/y 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
13a.Yield(gpm) la Method of test: Pg j r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H 7"774 Amount: 3 f,n'ltS