GW1--05289_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Je F&E't, Tkci er/Sa,,,n r C/6-0i) 14.WATER ZONES
Well Contractor N FROM TO DESCRIPTION
�k, 002- R ft ���1 ass
NC Well/Contractor Certification Number p� 18.OUTER CASING(for multi-cased was)OR LINER(If ap linable)
'22 '•-� I/I _/�-t �Je// //I•( ////1 1N 1FROMft. TKO,/(� DIAMETER THICKNESS MATERIAL
Company Name W 4 L 7 �/ / �� in to /2 S P!/G
'..-/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: • C). - /S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pets Its(Le.Cl/C.Counts State,Variance,etc.) ft. It. In.
.. 3.Well Use(check well use): n. It. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft, ft, 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: • i- R.
❑Monitoring ❑Recovery it, ft.
injection Well:
ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.6AND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENTNIETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Re m) ❑Other(explain under#21 Remarks) FROM ro DESCRIPTION(color,hardness,soli/rock type,erase she.etc.)
D It. 1 Q n• .•-c(0.y
4.Date Well(s)Completed:3 9-,--)('(Well ID# 'J S ft• L)/Ll/ ft. Vez,-e C/ .•-
Se. ell Location: ( ,H.
�� ft f�' f S!
: 1� -''''I (�-� t it ft.
Facilit Ot nor Name Facility lD#(if applicable) It ft.
1 � *7
ft ft.
& i i.•
/U Zr '•ei -1-er r _ • EN 0b ZOZ4
Physical Address,City,and Zip ft. ft.
U,n Io n o r �occt•O I1/9 21.REI4IARK3
T it.t�:r4.,c . t. •-art::-1Ua:,
County Parcel Identification No.(PIN) PA
Col
CfrG
5b.Latitude and longitude in de: es/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �y 22.Certification:
35. I&, iio N OQ • c2&l0 ! W
6.is(are)the well(s): Etl'Permanen or ❑Temporary S�Cert ontractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing w•1: ❑Yes bfe l No iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Weil Construction Standards and that a copy
If this is a repair,fill out known well co ruction information and erplain the nature of the of this record has been provided to the well owner.
, repair under#21 remarks section or on tl a back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed- p Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,on1y�GW-1 is need Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land su ace: Sip 0 (ft.
For multiple wells list all depths ff dhere it(example-3®200'and 2ploo) ) Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of sing: (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If wafer level is above casing,use"+ ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: i� (in.) 24b.For Injection Wells:Copy to DWR,Program,1636 MSC,Raleigh,NC 27699-1636d
crground Injection Control(IUC)
12.Well construction method: IC O! a r(i 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) J 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
I3a.Yield(gpm) r- L/_Method of test: f)/ r
13b.Disinfection type: H 7-!I Amount: '3 rt�% t t S