GW1--05297_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well
/�..-P Contractor Ikio� X-,
'
�; c,� Imo/CP� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
i,oq7O fL It.
3� 7 ft. ft.
NC Well
Contractor Certificationca Number •
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
/, iii.,///S /_ ,9 i I /� FROM PTOO/ DIAMETER THICKNESS MAT)RIIAL
Lny am / W // ! 111/vf / �//,L ft. 7 7 ft 6 b in. , c 50 �!/C,
Company Name D C�
. j��i 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: • `d FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. fL in.
3.Well Use(check well use): fL m in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muni ipaVPublic it. ft. in.
OGeothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPP CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ZO ft' Nei /1C Oise;"
❑Monitoring ❑Recovery ft. It.
Injection Well: ft.
❑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 ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.Derdness soWrock type Rratn size etc.)
D ft. 3 f. / f
4.Date Well(s)Completed: S � ' ZY�) G
Well ID# 3 ft. /d ft. /lit S/ ./.
Sa.Well Location: :.i /d ft, `/i/ n' 1�C </Ce- C
,., l!.J�� •
//C y4/ ft. y8d ft. ,i/!/ ////
Facility/Owner Name Facility 1D#(if applicable) R. It.
(XL �r-ot,� id toiL 3 ft. ft.
Physical Address,City,and Zip IL ft. k •L.A. r 41..': �t t "�
5-1 ,� /7 5‘6 21.REMARKS t,. 0 6 [511
County Parcel Identification No.(PIN)
1(4;- `'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (,;,'t r i�
(if well field,one lat/long is sufficient) !,. 7/n 22.Certification:
J . C--Vt/ 50ie 7 N gd> J / Z-Z, w /f� - 6`` g. C
. i
6.Is(are)the well(s): el rmanent or OTemporary Signature of Certified Well ontractor Date am/
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 iPlVo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair.Jill out known well construction information 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:
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: �/a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7�+ (R) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2®100')
' l 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+'•
11.Borehole diameter: /Zg (in.)
24b. For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
C Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /�-t7'Ta"�/ 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) g" Method of test: 21'7/
17 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 7 � Amount: /p/n"/-