GW1--05269_Well Construction - GW1_20240906

BL LL CO NSTRUCTYON RECORD«w
JThRZON7i
r Internal Use Oniy:1.Well Contracr Informat 1 /a, e-Well Contractor NamcES
FROM TO DESCRIPTION
36 ft. ft.
NC Well Contractor Certification Number - ft H•
" LL 1J •
15.OUTER CASING(for multi-cased wells)OR LiNER(if ap liable)�
/j wCi!I FROM 110 DIAMETER THICKNESS MA Company Name R /' R1AL
6.INNER CASING G OR TUBING(geothermal closed-loop) yG
2.Well Construction Permit#: �3 " !3 16. M TO J List all applicable well constructionpermits(i.e.UIC,County,State,Variance,etc.) ft. DIAMETER ( T1I1CICESS MATERIAL
M.
t 3.Well Use(check well use): ft m
Water Supply Well: 17.SCREEN
❑f1gr1CLLltUitll OMunicipaUPublic :FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Geothermal eatia Coolin Supply) ft. It. in,
fi S PP y) tesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) it, it in.
❑Irrigation ❑Wells 100,000 GPD 18.GROUT
Non-Water Supply Well: FROM
TO MATERIAL EMPLACEMENT METHOD d<AMOUNT
❑Monitoring °Recovery 6 ft. �� ft. �/771d171tf pat.( C`e a
Injection Well: ft. ft
°Aquifer Recharge °Groundwater Remediation ft. R.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if nppiicable)
OAquifer Test FROM TO I MATERIAL EMPLACEMENT METHOD
OStormwater Drainage ft. R,
°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#21 Remarks) FROM TO DESCRIPTION(color.basdaess,solOrock type grain sir*-etc-)
2 1� 0 ft. 5- R• C rg y
4.Date Well(s)Completed: 3--?/''Z/Well ID# 5 R. SO ft - t 1t- tlJ I 1 (etl''
Se Well Location: /
Xe—i ,,, J/v/ "&" 1 .0C—e-tk � `/ T f t �ti, R• f l r (
Facility/Owner Na Facility ION(if applicable) R. R.
60/D Gates /1 //,' ft. ft.
Physical Address,City,end Zip / ft. it. ` r I ' e�1-' '
/1/bh p O�/`036't71 ii 21.REMARKS F f is o$ ZOZ`t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tr,#o:-s c a ,' 4.-.., ar lint
field,one let/long is sufficient) 1? `= a
Al� �/,3CJ� 22.Certification:
3�,/L!/1 J� N 7‘70 /Q W
3`0—
6.Is(are)the well(s):*Permanent or ❑Temporary Signature of Certified Well ono-actorono-actorDate
7.Is this a repair to an existing well ❑Yes or %to By signing this form,ihereby certify that the well(s)was(were)constructed in accordance with
MA NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well consln,ction Information and explain the nature of the of this record has been provided to the well owner.
repair under#2I 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZOO (n)For multiple wells list all depths ifdifferent(example-3©200'and 2©100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3!7 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing us
•
ee +
6 (fr•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: rn
(in.)
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
J Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: PI)7 f,y
(Le auger,rotary,cable,direct push etc) 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:
,A 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ?� Method of test �!//' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: A"7 2 Amount: J/lrl fS