GW1--05300_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
•
1.Well Contractor Information:
i
/ '' ' 0C - ! k/ - 4/Gontractor Nand FROM TO DESCRIPTION
NC Well Contractor Certification Number eN7 ft. ft.
sA� if }� e 1D // 15.OUTER CASING(for mule-cased wells)OR LINER(If ap Itcable)
i'`�' f /3 11,1e I 1�l /h _LFROM��, { TO DIAMETER THICKNESS MATERIAL/�
Company Name T I%C/ 1 //T n. I 6 ren• I eZ /'Ut✓
•,,, �y / 16.INNER CASING OR TUBING(geothermal dosed-loop),
2.Well Construction Permit#: W b FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Srate,Variance,etc.) ft. ft. In.
3.Well Use(cheek well use): • IL ft. In.
Water Supply Well: j 7.SCREEN
DA Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public R, ft. tn.
DGeothemfal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft: 1t. la.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
Cl irrigation ❑Wells>100,000 GPD • FROM To MATERIAL L EMPLACEMENT METHOD tR AMOUNT
Non-Water Supply Well:
C, IL Z} ft. f6dn/TL p
iteere
OMonitoring ❑Recovery V ft. fL
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. R
OAqui&r Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage fr. ft.
DExperimental 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(weer.hardness satveoue errs Enna size.etc.)
4.Date Well(s)Completed:3-'&g".Zy Well1D# /67 it %j,•s rr. broai 5ICT(`r)-
5a.Well Location:
��f �, �c 7 �C�L+,.� /'�sR' �1/0 � b 1 u-c �'t�}-E,
c:/ ,36 rt. ft.
Facility/Owner Name Facility ID#(if applicable) R. R.
Zy3 {rrk d , . zSoO ' ft ft.
r-
Plfyeical Address,City,and Zip I'L ft. f ;`�, s; •;.,
5742•1 `/ gs-9 21.REMARKS ` 0 �I+
County v Parcel Identification No.(PIN) S`P 6 2D24
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: typ•A n
(if well field,one lat./long is sufficient) 22.Certification: D s:r: ', (%hut
35.35yii/ N 5(r), zg36Z3 w t,;,;.,�
�� ! � z� ji______ 3 - 2. -Z.�
6.is(are)the well(s): VIt ermanent or ❑Temporary Signature of Certified Well Contractor Date
/ By signing this form,!hereby certify that the wet!(s)was(were)constructed in accordance with
I
7.Is this a repair to an existing well: ❑Yes or liK /SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!noun well construction Information and explain the nature ofthe 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:
You may use the back of this page to provide additional well construction info
1.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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
Z�/
9.Total well depth below land surface: �t2 (ft)
For multiple wells list all depths fdgjerent(example-3Q20U'and 2(t�100) Submit this GW-1 within 30 days of well completion per the following:
t (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: .0�
If water laud is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For lnlectlon Wells:Copy to DWR,Underground Injection Control(TUC)
�/ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AI X R0 7r4-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 dep
artment of the county where installed
FOR WATER SUPPLY WELLS ONLY; 24d.For Water Wells producing over 100,000 GPD:Copy
13a.Yield(gpm) / 2,/ Method of test: 4 j, Permit Program,1611 MSC,Raleigh,NC 27699-1611 to DWR,CCPCUA
136.Disinfection type: f1 7-i/ Amount: 4,