GW1--05846_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Worm
don:
1� �iF�V.lr1Qil 4fi 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2©:6 9 ft. i6d
ft-
ego ft. Z5att.
NC Well Coa/tractor Certific ion Number L/ /// 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Ilcable)
L zit
t !/I'i/��) FROM TO ' DIAMETER THICKNESS MARIAL
Company Name C6 7 t/�2t-fL 6(.� fr. 6 1/0 in. s Zi7 0 I�f Q INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: . Ci ( /. - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count.State,Variance,etc.) ft. It. in.
3.Well Use(check well use): rt. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OM�unicipaVPublic ft. IL In.
I
OGeothermal(Heating/Cooling Supply) ili sidential Water Supply(single) ft. ft, in.
❑lndusttial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Olrrigation ❑Wells>100,000 GPD FROM TO AL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Zd ft. ��by., e /Q11ee
❑Monitoring ❑Recovery ft. rt.
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
❑Aquifer Test• ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEsc PTION(color.hardness roU/rotic type grata aiu etc.)p 0 IL i0 ft. ���
4.Date Well(s)Completed: O%I/-eq Well ID# /0 it 6 q ,ja /al 4
5a.Well Location: :-i 644 ft. ydt) ft- / 4,e. 5,) 7L
/Sc,i ci,✓Ot.JaXP,,A ft. ft.
Facility/Owner Name Facility 1D#(if applicable) fL ft.
65/7 AZ-4.?,G ACA4er-i1 /0 ft. ft ,) 1 ;
Physical Address.City;and Zip � / ft. ft.
Ur/G� 06 "t/QT!J -W-L4 21.REMARKS . ,
r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
. 7,'76- 3.ss/ d 1 N D 0. 7Z3 3 W t
6.Is(are)the well(s): E.l rmanent or ❑Temporary tgnatuhre of Certified Well Contractor Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Me /SA NCAC 02C.0100 or ISA 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 remark 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: � 24.SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: 7 00 (ft.) 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 level below of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
1fwattar tic wateris abovel casing,use top (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(lUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 740�� 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) /5 Permit Program,1611 MSC,Raleigh,NC 27699-1611
-��1 Method of test: 2 /�'
13b.Disinfection type: 14// T! Amount: J,1 S