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HomeMy WebLinkAboutGW1--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: