GW1--05823_Well Construction - GW1_20241001

VY II LL L U1N 01 KU L lion K.LCUKL(U W-1) For Internal Use Only: '
1.Well Contrite Information:
' 14.WATER ZONES _
Well Contractor Name FROM TO DESCRIPTION
ft. / 0 ft.
ao3cep ft. /5-o it
NC Well Contractor Certification Number
r I I� /f 15.OUTER CASING(for multi-casedwells)OR LINER(if ap li
/FLU/ n/'`�' FROM TO DIAMETER/ THICKNESS MATERIAL
Company Name (� 6 /y R LO/ in. .� 5' PC) ci
16. R CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State,Variance,etc.) ft. ft. in.
t 3.Well Use(cheek well use): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑M� unicipaVPublic ft. R. in.
❑Geothermal(Heating/Cooling Supply) 4Kesidential Water Supply(single) ft, ft, in.
❑Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. R. %4/ffs. T /'P 1 eo �4✓
❑Monitoring °Recovery ft. ft
Injection Well: ft R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK 0t 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) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWrock type,grain size.etc.)
O it /© R G(O.v
4.Date Well(s)Completed: 7-//'Z y Well ID# /O ft. /g ft. Sh,(i i 4 / S'e 5-/a'/7r"
5a.Well Location: ` ` /e5 it S R. 5 Ili.ki t f e,
VjCk
410,1 S_ /e . Nk4�►1ar6 "$ -©a / /
Facility/Owner Name Facility ID#(ifappl able) ft. R.
87 30 Locktr C Icss _Zde. ft. It. . . , • _ •
Q
Physical Address,City,and Zip J /� ft. ft.
G1,i/Ova QS-o/j-OQ‘ 21.REMARKS iI 1 �. ,'l
County Parcel Identification No.(PIN) t_
r, . ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification: //%��
wit e'
35: 1-7 zyz N go. 705/ / W � .
6.Is(are)the well(s): ermanent or °Temporarygna[trre ofte:ehified Well Con or Date
By signing this form!hereby certify fI'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or IQNo ISA NCAC 02C.0100 or ISA 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)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: do0 (t) Submit this GW-1 within 30 per days of well completionthe following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100') y p
' 15/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
' ((water level is above casing.use"+"
//
11.Borehole diameter r (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
/ Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /1IJ PO T/3RY' 24c.For Water Supply and Open-Loop Geothermal Return Wills:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY/ F/WELLS ONLY: n �f 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /5 Method of test: //� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: I/T 1 Amount: /r l"y T