GW1--05845_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1ç \* \
Well,Contractor Information:
1-.0�l(S 14.WATER ZONES
ontractor Name FROM TO DESCRIPTION
aJ`\ qG ft. I 's- ft.
`( ( Jeo ft. ft.
NC ell Contractor Certification Number W
biiV
15.OUTER CASING(for multi-cased wetly)OR LINER(If ap l[cable)
t f FFRROM TO DIAM ER THICKNESS MATERIAL
'� Ili {' __� .T‘ rt ,(7 ft b/ie in. 02.3- PVC
Company Name
!!'' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: t `t FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County. ate,Variance,etc.) ft. ft. in.
-
3.Well Use(check well use): ft. rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. R. in.
❑Geothermal(Heating/Cooling Supply) l3Aesidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: 0 ft. .Lc) ft. pil bn 4 e r
❑Monitoring ❑Recovery ft. rt.
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test• ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 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,hardness soWrock type grain size etc.)
``� n It. 20 ft. t el Glay l `
4.Date Well(s)Completed:9'�'•>'. • Well ID# ft G S ft b pr, ^ 1 e`)
,,, S �
pik ellL_oca"�n: 6S" rt- Z2Tf` ��VG slam .
ft. ft.
NC-111 ea us CcOte----
Facility/Owner :Facility ID#(ifappli ble) ft. IL
41aI 5c �\ �� ft
Physical Address,City,and Zip rt. ft. i'
UrZ 0 --) 6i] : 135n6)C.. 21.REMARICS
County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,d,one lat/long is sufficient) 22.Certification:
(i
k.� \q55 N '' O . k.Br Oc? W Z14-4
1-6114-
6.Is(are)the well(s): yl�ermanent or OTemporary Signature of Certified Well Contractor to
' 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 I NO 15A NCAC 02C.0100 or 15A 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 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 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: ^d'5 IN 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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
, 10.Static water level below top of casing: '-70 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(1UC)
11.Borehole diameter: g_ \(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: C 'e1 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) \� Method of test: 1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
11\13b.Disinfection type: 4' Amount:V"'