GW1--05849_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
3 ef7�rev /c .c/rf r/Ga [Jj/') UTh4GA$OY! 14.WATER ZONES
Well Contractor N rile FROM TO DESCRIPTION
%oa ,� �s� 1g5J �. s
R. ft. a3 0
/N�CJWeI/l Contractor Certification/ Number / �] / 15.OUTER CASING(for multi-casedlt wells)OR LINER(if a licable)
s L. f GGL//j L..- !/ Uri'!//, rit./c. FROM �3 l� ��TO R ' THICKNESS 5SS MATERIAL
/ ft ft. / in. a p v C.
Company Name •
2.Well Construction Permit#: 11517• t2 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consm.ction permits(Le.UIC,County,State,Variance,etc.) ft. ft- in.
„ 3.Well Use(check well use): R. R. in.
t Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. In.
❑Geothermal(Heating/Cooling Supply) rditesidential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. c2 Q R. ?3eniAeu',r f r QOGI�CCi
❑Monitoring ❑Recovery ft. it. !�
Injection Well:
ft. R❑Aquifer Recha
rge ❑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.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONf rotor,hardness soWrock type,grain size.etc.)
p /// b ft. 01(� R. She//$7<orte / p�c,-
4.Date Well(s)Completed: /- 'ail' Well ID# 0 n- L./ 3 rt. 13'64.-e .'(.
5a. ell Location: ( Mt
&TK
tGl/3 ft. c2:510 R. V Lc.. , �j..c.,. '
UJ0i'k5 ft. f.
ility/Owner Name Facility ID#(if applicable) R. n•
2 2 9 /Yi;ti Grove Rd ft. ft.
fr
Physical Address.City,and Zip
R. ft.
Uri, on 042 ar1QOQ5 21.REMARKS !;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) C Q p 22.Certification: p �/
35, l g a K3 N 8O, 5 '5 OI W f -L1- o2-7
6.Is(are)the well(s): 2manent or ❑Temporary Si o e d Well Contractor 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: ❑Yes or *I' 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 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 0
(,J 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / d (ft)
For multiple wells list all depths if different(example-3®200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
, ?S 24a. For All Wells: Original form to Division of Water Resources (DWR),
, 10.Static water level below top of casing: .J (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use//"+"(D 11.Borehole diameter: //g' (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
p Program,1636 MSC,Raleigh,NC 27699-1636
/`12.Well ' .-•. ction method: 4-/-n/% 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auge rotary,'.ble,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) A ' Method of test: /9 i 1�' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 4!f Amount: 3 e i.n 7I S