GW1--05290_Well Construction - GW1_20240906

♦r iL.L.1.t.F.oha I EN-Li a.i ivi. 1s.ii&viwL(V VV-i) ror internal use only: I
1, ell Contractor Information:
„� ' , � Tr) .
ek kh n Cc_ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
a_13-5Q, R. ft.
R. R.
^^^NC���Well ContractorCertification Number �\ ,brui 15.OUTER CASING(for multi-cased wells)OR LINER(If ap Ilcabte)
' \( U t I t` 5 Well
.1ittFROM/�iL TO
ftDIA{INETERin. THICKNESS MATER,IA/I./�Company Name \ Il1����J�` ` 1 /T/ �� C�/� 12 j�V(r
DL
s 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 ^ L FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIG County. ate,Variance,etc.) R. ft. In.
3.Well Use(check well use): It. rt. In.
- Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic rt. ft. in.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, R, in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO ;ACRItL EMP CEMENTMETHOD&AMOUNT
Non-Water Supply Well: D ft. Zo R. �f ,,u,'
❑Monitoring ❑Recovery ft. It.
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test• ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control R. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal FROM TO DESCRIPTION(color,hardness,solProck type,grain size.etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a ft. /O ft. ``G tot
'L�
4.Date Well(s)Completed:O ---1-4)/Well ID# /0 ft 3© ft' bro it S Ian
5 .Well L cation: :-i Lw*
R 53 ft i/ /� u 5 �vlaf`�
acility'/Owner Name FacilityID# if a ft. R.
(0 1 Li CfSr-L''Sn'G e.M bie-:WV\1AY ---- ft. ft.
Ur
I Address.City,and Zipt f�f'1 I�y(��1 21.REMARKS S Ep 11 6' 2024wuty ti Ja s CliParceell Identificationl No.(PIN)
V V L Y
IMo:rrt..;C,l ,1- ^4,4,-y uhlc
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Qyv pa
(if well field,one Iatllong is sufficient) 22.Cert icatIoon:
341, 7OSDa�g C.N 0 9/5 t/ / w ,� �v;vv Q-Z,?rZg
6.Is(are)the well(s): I:SPermanent or OTemporary Signature of Certified Well Contractor 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 well: ❑Yes or Apo ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill out known well construction information alain the nature of the of this record has been provided to the well owner.
, repair under 11.21 remarb 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
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
Ga 9.Total well depth below land surface: aC' (ft) Submit this GW-1 within 30 per days of well completionthe following:
Far multiple wells list all depths ifdifferent(example-3@200'and 2(4)100') Y p
• 10.Static water level below top of casing: / ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+; Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: / ' (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: iC r:0'12� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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 D
Permit DWR,CCPCUA
13a.Yield(gpm) I Method of test: 4/ Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: TN Amount: 3/4-k5