GW1--05900_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Inforrmmation:
. eFfce� `C,c 4e/"/Uc.0 C�tc/7S0/7 14.WATER ZONES
Well Contractor N FROM TO DESCRIPTION
I/60 a R ISS1 i 7S� �,35
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)
)OR LINER(If ap Ifeable)
�. FROM TO DIAMETER THICKNESS MATERIAL
4:-. Mc.//r.5 Wet/ ,9r';(/; Z/1JC.-. ft /.3 oft. (I %in. d2 S P(/
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: C#4 A ^ L1J e a Oc i-i ' (viol 9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fa rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. it. in.
OGeothermal(Heating/Cooling Supply) gifgidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. of? 0 ft ��
❑Monitoring ❑Recovery ft. ft.
Injection Weil:
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 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,t,.rdaeu soWroelc type,grain size etc.)
q L/ ov nod c�� ,
4.Date Well(s)Completed: ! - T•".2.7 Well ID# a 0 f4 1.2 D R• jI _}. �j J�!`�,
5a.Well Location: :,t f 3 0 n'�[ G.,� Gi
la o ft. �. 7"yt• �,C��4 e
Podney c m Qre /30ft. a d`' VLL,e G
Facility/Owner NSme Facility 1D#(if applicable) R•
/o "l 4/3 /2ob, n,So 1i chk_rcA R.J. ft ft.
Physical Address,City,and Zip ft ft `,
21.REMARKS
arrkS I { t' "
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I. .. •r„. S :�
(if well field,one lat/long is sufficient) 22.Certification:
35. a 63 1 N gel &1103321 W
6.Is(are)the well(s): (Der tmanent or ❑Temporary S� Well Cony tractor- Date
� � By signing this form,I hereby certifythat the well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or lif'io ISA 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 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: (7 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: , , ('0 (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3®100'and 2®100)
10.Static water level below top of casing: 3 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
limier level is above casing,use"+ Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (/ 0� (In.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: fl fl ! 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:Cop
y to DWR,CCPCUA
/ 0 Method of test: I t 1, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) tom!
13b r.Disinfection type: ` T7/ Amount: 3 p; /1+5