GW1--05242_Well Construction - GW1_20240903

"_ "''"1 For Internal Use Only: .
I.Wei,Contr. tor 1 tion:
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
-T eft. , 60ft,
NC Well Con ractor Ccni anon NullityR�.... ft ,1M1111111111111111....
rJ' ` tnI
CASING(for mult-cased wns OR LINER If applicable
+d F Oar TO I
DIAMETER THICKNESS 4
Com any Name I {IL ft• 3 ft'
t le l' r in. M fATEtuAr
2.Well Construction Permit : 16.INNER CASING OR TUBING jgeothermal dosed-loo IIII1
MIll
FROM TO DIAMETER TRICIOIESS MATERIAL
List all applicable well constrtction pennies(1,e.U/G County,Stale,Variance,etc.) fc ft.
to
t 3.Well Use(check well use): ft ft .
in.
Water Supply Well: i7.SCREEN
kicultural FROM TO DIAM ETn:A SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public
thermalft. ft. in,
(Heating/Cooling Supply) OResideDtiai Water Supply(single)
OIndustrial/Commercial ❑Residential Water Supply ft.
L ft.
n pP Y(shared) 18.GROUT
Oitrigation ❑Wells>100 000 GPD FROM
rt.
Non Water Supply Well, MATE SAL EMPLACEMENT METHOD&AMOUNT
J�
❑Monitories ❑Recovery ©R ►l t i 1 1
R. rt.Wen:
❑Aquifer Recharge ❑Groundwater Remediation rt. R'
❑Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Test ' FROM TO MATERIAL EMPLACEMENT METHOD
❑Stomtwater Drainage ft. rt.
❑Experimental Technology ❑Subsidence Control
ft. ft.
❑Geothermal(Closed Loop) OTtaccr
20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Henting/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO
DESCRIPTION(color,hardness,soWrnck type,grain slu,etc.)
` it. ft. v
4.Date Well(s)Completed: '0( �.f Well IDI# 'e i..y Ci
tit R• 3 R, ' 1(•.ks1 _ ,�q
s�Well Locatio 5rt fn Y•, 1j
IT
fc ft.
Facility%ow ner N me Facility IDtt(if plicablc)
R. R.
c;i2
Rc1
fc ft
ysical ddress,City,and Zip
ft.
� It.
C ►Y -1 .� 21.REMARXS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld,one laUlong is sufficient) _ !—�
36 96) 7 ! 1 g.a t 'd 'I b W Z2.C cation: 4/
6.Is(are)the well(s): ❑Permanent or ❑Temporary /��"" /
Si ure of Certified Weil Coontractor Date
7.[s this a repair to an existing well: ❑Yes orBy signing this form,.1 hereby cergfv that the well(s)was(mere)constructed in accordance with
!St NCAC a2C,0 or NCAth Ore'.0200
ten iYe11 Consttucelori Sttnrdards and that a copy
!fthishi is r repair aftknexiteencwetructionbYrsnator aho
plabhtinenaurreajthcof repair under te2I remelt.section or on the back of this form. this record has been provided to the twrl!owner.
23.Site diagram or additional well details:
3.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: 'I Cc)
For multiple wells list all depths if different(example-3@200'and 2Q100� (ft.) Submit this GW-1 within 30 days of well completion per the following;
10.Static water level below top of casing: 24a. For All Wells: Original fonn to Division of Water Resources (DWR),
If water level is above casing,use"=" (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ' (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(WC)
-, ; Program, 1636 MSC,Raleigh,NC 2'7699-1636
12.Well c uation method:
.auger, toy, blc,direct push ere) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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) Method of test: CAAt.+ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: