GW1--05298_Well Construction - GW1_20240906

Tr ril�lt l.vi\a1 nU1.11l n KJi.CUKU(UW-1) For Internal Use Only: •
1.Well Contractor Information: I
�( 7 e FFr`eii i4 G c, p� G.t.v;n CToL,C As O"I 14.WATER ZONES
Well Contractor N e FROM TO DESCRIPTION / �•
/ ft. It. 5- gl �l -,0 o L aJ
‘- L/J 0 a 6 ft. ft. /I G>7J LSJ i I e
NCy�Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap llcable)
✓1/ C. /Y1 //,S J e d pis t t/t M /C FROM TO DIAMETER THICtKNESSS MATERIAL
Name 4_ ! i] 6
1 I 33 �Q 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: `A, I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance.etc.) rt. ft. in.
3.Well Use(check well use): ft. IL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipailPublic ft. rt. In.
OGeothermal(Heating/Cooling Supply) ential Water Supply(single) ft. R. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. V�l ft. 7)
❑Monitoring ❑Recovr-etlrs.�T .OAt...t4�_
ery ft. ft.
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
0Aquifer Test , OStormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness aoiUrocre type grain size etc.)
4.Date Well(s)Completed: 8 1/q-c 17 Well ID# Q. 0 ft I/Li ft. 23(et, ,
Lre
5a.Well Location: ._� Li l ft. a O dt' Vl 6 '
�q^ ar;t ft. R.
Facility/ Name VJ�1 Facility ID#(if applicable) ft. ft. _ / '
Physics Address,City,and Zip ft. ft. S El' 0 6 1024
' ` 4O/LfJ,. 21.REMARKS
infor iaa'n r••,'sna,:'11 Uvdt
County Parcel Identification No.(PIN) j)+Art".-('!r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatllong is sufficient) 22.Certification:
33, 1?t,a 9 ' N 'o . 5V34/3 w e -z a4'
6.Is(are)the well(s): ® manent or ❑TemporaryiaCe ' ed Well Contractor Date
Per
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 etrro 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fell out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 rentarkr 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 G3-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a 00 (H') 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')
10.Static water level below top of casing: 3 (ft) 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: f0 //$ (In.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /?0 74a r . 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) 0")�/3 Method of test: ry/•/' Permit Program,1611 MSC,Raleigh,NC 27699-1611
IT 13b.Disinfection type: 7 / Amount: _3,e i n-i-s