HomeMy WebLinkAboutGW1--05847_Well Construction - GW1_20241001 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor /
Info1)01
on:
CIT1 S 1�Y 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft.
NC Well)ContractorMCertification Number ( (1�\ �/�\, 1 / 15.OUTER CASING(for multi-cased wells)OR LINER(If ap llcable)
f \/ l o l��1 C 1) - D �i 1/ . y L'(1 h Q FROM TO ' DIAMETER THICKNESS MATERIAL
Corn-paVny`Naame J\ V w�VJ JI V Oft C t g ft. Il p in. •Z<-D PVC
. U �j 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: , 1 D% FROM TO DIAMETER THICKNESS MATERIAL/
List all applicable well construction permits(i.e.U/C.County.State,Variance,etc.) U ft. 5-if ft CT L to `Zc P Y`
3.Well Use(check well use): ft ft. in.
- Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic it. R. in.
OGeothermal(Heating/Cooling Supply) LBft�td al Water Supply(single) ft R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
0 Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 5 !� ft. / .L J POg
❑Monitoring ❑Recovery ft ft ,` t`�
Injection Well:
ft it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity 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)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM it TO ft.
DESCRIPTION(color•hardness soil/rock type grain size.etc.)
A
4.Date Well(s)Completed: !/3/2-1) Well ID# ft. ft.
5a.Well Location: ft. ft
Oar-, `'uIf -t ft ft.
Facility/Owner Name Facility lD#(if applicable ft R.
5114 ✓ 4COCtC)t L0(1,4) /Y)onYot ft. ft 0 1 ,-,,,
Physical Address.City,and Zip 22 l YL ft- ft•
ll ff U ir.. ..'.., r
`•'l,1^j'D t>1 O ( -I I o( 21.REMARKS L,
County Parcel Identification No.(PIN)
5b.L`illtude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifies n:
3SO • on 11c' 9 N 20, 5-27114 W
� q/3 / LY
6.Is(are)the weli(s):t•B'Permanent or ❑Temporary Signature of ed CoqtosetOr Date
/- 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: eili s or ONo I SA 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 erplain 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
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9.Total well depth below land surface: T/-f1 U (ft)
For multiple wells list all depths ifd different(example-3Qa 200'and 2®100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3 ( ) 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: kP i(ib.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(lUC)
/�
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4 i 2 4('""�°) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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,
/J �/► CCPCUA
Permit
13a.Yield(gpm) / 7 Method of test: nr.2 Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Ti f 8 Amount: 3 d r//S