GW1--05247_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.`Well Contractor Information: •
Lt L InJ
I4 !/r/I t� / ,4/G4." ACC, 14,WATER ZONES •
Well Contractor Namc FROM TO DESCRIPTION
7a It. ft.
2.036'
ft. ft.
NC Well Contractor Certification Number _
///J /��/J /) /n/I 15.OUTER CASING(for multi-cased wells)OR LINER(if a 1lcabie)
o •G.. /r r a I i l r //!�J// `FROM TO DIAMETER THICKNESS MATERIAL
Company Name ,�LI 4// ft. `/P i7) D- l7`7$' in. i Zi7 ✓/i//
'7 r. 2 16.INNER CASING OR TUBING(geothermal closed-loop) /`� Cs
2.Well Construction Permit#:G 4-L✓6 ZOLj/ -t'X,y36 FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.UIG County.State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
;FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�M/uoicipal/Public p. R, ill.
❑Geothermal(Heating/Cooling Supply) 1,7Residential Water Supply(single) R ft. in.
•
❑IndustrialCommercial ❑Residential Water Supply(shared) I.S.GROUT
❑Irrigation ❑Wells'.100,000GPD . FROM TO MATERIAL EMPLVEMENTMETHOD&AMOUNT
Non-Water Supply Well: O it. ZO ft.
pervf❑Monitoring ❑Recovery ft. R. fQ� G Gil✓
Injection Well:
uifer Rechargeft. ft.
❑A
q ❑Groundwater Remediation
uifer Storage19.SAND/GRAVEL PACK(If applicable)
DA q and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control rt. R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES RIPTION(color,hardness,sell/rock type Grain size eta)
�/ d n. /o ft. Ore*Nr. l wfk
4.Date Well(s)Completed:7 "/--2-i 1/ Well ID# /0 It. (J'Li ft. � ' G 5 IL,
. u rw G
Sa.Well Location: 4. I/q h• 500 ft' ,/uG 5/ere •
i4)1e61941. 7-0/ 5 ,„,,e Lect,t -
Facility//OwnerN Name ✓Ai.
Facility IIN(if applicable) D•
z.
rt. rt.
ft.I /t/li.
Physical Address,City,and Zip IL
A+abraffll 21.REMARKS
hy
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
35'Z 73906 N Ira g 6/7/ w
6.Is(are)the well(s): N ermanent or ❑Temporary Signature of Certified ell Contractor Date
By signing this form.(hereby cert(Jir that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t IN i. 1SA NC4C 02C.0I00 or ISA NCAC MC.0200 Well Construction Standards and that a copy
If this is a repair,Jill out know,,well construction i formation 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:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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:
2 24.SUBMITTAL INSTRUCTIONS
3 9.Total well depth below land surface: 00 ft
For multiple wells list all depths ifdderent(example-3®200'and 1©100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ?j Jl 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,ase/++" (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: / (In.) 24b.For Infection Wells:Copy to OWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
Q county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Co® Permit Program, Copy to DWR,CCPCUA
13a.Yield(gpm) 6. Method of test: JIf 16(I MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: ,VTt/ Amount: 1'/1lry7t'f