GW1--05912_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor In rmation:
,i)1.11✓1 ki go__ %ce 14.WATER ZONES
Well Contactor Name FROM TO DESCRIPTION
z,G3G 70 ft /60
R. ft.
NC Well/J Contractor Certification Number - 15.OUTER CASING(for multi-cased wells)OR LINER(If ap liable)
// , Ai//y //(I- , _I/
�t /� FROM TO DIAMETER , THICKNESS MATERIAL
Company Name A? �� •></7L ft. 67 ft. 671. in. /2._s4 /iiG
. /.�/ / / 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: . /( �/�/lb 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): rt. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
cultural ❑MunicipaUPublic ft. ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL E CEMENT METHOD do AMOUNT
Non-Water Supply Well: p ft. ?_.D ft. /;Nett.tie LC
❑Monitoring ❑Recovery rt. It.
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' ❑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 DESCRIPTION(color,hardness,soturocktype grain she etc)
IL 5 n. c/a /
4.Date Well(s)Completed: 7' Zy Well ID# S ft /. ft Sa d7
5a.Well Location: :_z /2 it. ft. c la
e,-F-'G 1 �}o ft aft. blue I en - bq lfQ -4�4C
Facility'/Owner Name, �1- 1 lFacility iD#(if ,0liable) �p 7 ft' 2-OQ ft' 6((,(f S Jgf{J
Z39q / GrG.� 1, TT/ iC�l it ft.
Physical A s,City,and Zip ft. ft.
lT/!ISOA. 6-95
i0093 i01 21.REMARKS t ' '- ` .,
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: ' 4'
3 4. g / /Zi N ge• 33 `7t W � . • : _ . `g a L1
6.is(are)the well(s): Z1Pi<rmanent or OTemporary
Signature of Certified 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 81411( I 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 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' mayin Remarks Box).You also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z OC) (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q2000'!'and 2@100')
10.Static level below of casing: 37 (ft') 24a. For All Wells: Original form to Division of Water Resources (DWR),
limiter10.Stlevel wateris above casing.use top Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 � (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Zoa,� 24c.For Water Supp 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) 'C7 l L Method of test: 4j j✓ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: f/ 7Ty' Amount: 3,1H,