GW1--05296_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: J
1.Well Contractor Information:es/I//wt / A k, /�lss . ce 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
z4oft. yg o.
Z03 6 ft. ft.
NC Wellll Contractor Certification,/ Number -
n 15.OUTER CASING(for multi cased wells)OR LINER(If ap Ilcable)
r`/ �/f'I� I�s ' '�l/ {�I/� FROM TO ' DIAMETER THICKNESS MA RIAL
Company Name/,/ ! r✓V ..J// t, ,///L ft- /, ff. [/e in- , Z lC fvC
LJ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: • / o 83 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,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 ❑Municipal/Public II. it. in.
OGeothermal(Heating/Cooling Supply) IIII sidential Water Supply(single) ft. ft, in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
°Irrigation ❑Wells>100,000 GPD FROM TOMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. ZO R. .1 tc - ,Act
❑Monitoring ❑Recovery ft. ft.
Ace'
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test' ❑Stormwater Drainage ft. ft.
❑Experimental Technology °Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracts 20.DRILLING LOG(attach additional sheets Ifnecessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness wWroelc tree grain size.etc.)
�/ Q R. ft.
4.Date Well(s)Completed: Well ID# ft. /.!r ft.
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5a.Well Location: L. :i GzalNe._ 4ft00ft.//Jr ft. rq R slide. S/d L
//C h I/ .wbc c- , J ' /) f/
Facility/Ow__nerName J� Facility ID#(if applicable) rt. ft. __ _
//
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P.hysical Address,City,and Zip R. R.
�44-tr/ `//Zi5-6 5- 21.REMARKS r Y 9 d 2024
County Parcel Identification No.(PIN) IritG:n",r., rt., .- ' Ua i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 7�r t$�`"'
(if well field,one let/long is sufficient) 22.Certification: 7 L)
3. , Z g`i N gid, 4 ,+y e 7,7 W ge � - ?g- / - ,
6.Is(are)the well(s): rmanent or ❑Temporary Signature of Certified Well Contractor Date
Ii i
__� 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 I771Vo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of d ie 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:
•
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 I 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: 5/y-�� (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t0.200'and 2®100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 56 at) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing.use/"+"
11.Borehole diameter: (? �� (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
i Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /t-0-t.Q--1...._/ 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 DWR,CCPCUA
13a.Yield(gpm) I Permit Program,1611 MSC,Raleigh,NC 27699-1611
/J Method of test: /✓L
13b.Disinfection type: I/7 Amount:�/r1 T S