GW1--05887_Well Construction - GW1_20241001

WELL CONS L KUC'I'LUN RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1/41-e FFy p, I-i ,C Aer,"�a toit,"n J C./esa•--, 14.WATER ZONES
Well Contractor N c FROM TO DESCRIPTION
y(o 002 "9 ft.
ft. ,50 150
It. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
C?L L. ,v .11,3 �P i / 22r l r 1! ^Cy -�C FROM TO DIAMETER THICKNESS MATERIAL
Company Name / / .{-•. / ft. 179 t' it. 19 �q in. 0 C Pa C
16.INNER CASTING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: _3 8 98 A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State,Variance,etc.) ft. ft. is
3.Welt Use(check well use): rt. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural °Municipal/Public ft. It. In.
OGeothermal(Heating/Cooling Supply) tiiF idential 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: a ft ,1 0tt
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test °Stormwatcr 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 TO DESCRIPTION(color,hardness,soil/rock grain size,Oz.)
�j O ft. .2 it. She// goc/
4.Date Well(s)Completed:-! 'if/ '021/Well ID# a 2 4 L. `/AgZe..
j e G A.�u
5a.Well Location: :-i L/ I./ a0ot `
ft. . , a'&e. .P ,gam-',
110Pos 9tzterz LOCUSi- MI ft.
ft.
Facility/Owner Name Facility ID#(if applicable) ft• rt.
gL/673 hi.ertin Groti. Rd. ft. ft. o ; ,� ,,
Physical Address.City,and Zip Ift. ft.
37lA 4I1/i H Il/! 21.REMARKS ;fa: -
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:
35. 3575c7 N SO. 3 83y/ W q_i8 -a �
6.Is(are)the well(s): Y7lrermanent or OTemporary S FuWell 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 fs1< 15A 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#2/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�W-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: C:2 412 O (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii erent(example-3(0200'and 2@100')
hi 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
' If water level is above casing,use"+"
11.Borehole diameter �f; (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /1.D 71-0,r y 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 Q
13a.Yield(gpm) (')I Method of test: %f Permit Program,1611 MSC,Raleigh,NC 27699-1611
f7 13b.Disinfection type: Y H Amount: 3 j0 i Yr+1