GW1--06336_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informalio9: i
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FROM TO —DESCRIPTION r
Well Contractor Name
li 3 ft. a.40 ft. i 1.31 f
NC Well Contractor Ceb , 1rtifilggtionN tuber q g :,:dg;AB.TEAS R ING.(fof"iiiiii i a ells`'C3#1fi FER'(tt' p 7feabTe} z nT;;t;;i::
�r�7 � � (� ¢ �j qt V�Q pAT * FRO
OM TKO sft. DIAMETER TRIMNESS MATE9RI/AL
Company Name ;Its'l E COMINOr i5 CIMAXWO011ikiiiia liii ltitllilxNO,01: 'D,-,3,
2.Well Construction Permit#: C,o tt 1 O 0 1 . 1 FROM TO DIAMETER TRCKNESS MATERIAL
List all applicable well construction permits e,Ul ,County.State,Valiance',etc,) it. ft. , In.
In
3.Well Use(check well use): IL ft. '
'Water Supply Well: �'1,SCRON:4 7..r:- 4 Y...F1.l .sWA. -sc{ M ii P. V.g1.5.,.:1-a' `ig
FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. ft. In.
['Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. th.
Olndustrial/Cotnmercial OResidential Water Supply(shared) :1t3 Q, ,,Y}Vr n li, o, tug, 1R. .. -}a ^ y g;gc
❑Imgation ❑Wells>100,000 GPD FROM TO _MATERIAL 4 EMPLACEMENT OD&AMOUNT_
Non-Water Supply Well: •0 ft. /O it' 6eirl f'il F, k'"A 4i 1 ; ,
['Monitoring ❑Recovery ft. ft.
Injection Well: t'
ft. ft.
❑Aquifer Recharge ['Groundwater Remediation
':;,18a:3i-1VI/O A'S rZ+7'KOK°(1(;sp icable}a i.z ,r ,c 1:":)` : 'es.,H . t
['Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage ft ft.
['Experimental Technology ❑Subsidence Control ft. ft. 1
❑Geothermal(Closed Loop) ['Tracer i dtrk6Ft1L'TsINg'I.F1 :E9f' t diI(Rii iiliIat5'ifrAECaSStir'y]r'Wi3s s•,, +; t
FROM TO DESCRIPTIOiN Ccoiar,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks)
in) ft. (Ci it. f einet
4.Date Well(s)Completed: S ".1
3- .i1 Well ID# 16 ft. 3 oo ft. q 0`t 1,�i t-1., (o/f/j .
5a.Well Location: ft. it `-
nO r1 \ to ek ft. ft. T r, ...
Facility/Owner
��Name I Facility ID#(if applicable) ft. rt. " '":,,,,,1.,_ 'e 4_•>,
3 M,'or Per-keit-Sal ft. fr. III.T 2 2 2024
Phy ical Addres City,and Zip ft. If' • r r
.ems, Ji p, }; t 1 s >; 0 .N ;W= Wgt,,u,. ,,-• ?�;� :
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:
N W /9 22 1'3 -21
6.Is(are)the well(s): permanent or OTemporary Signs of Certified Well Contractor Date
By signing this form,I hereby cert(that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I o ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fr11 out known well construction Information and explain the nature of the of this record has been provided to the well owner.
repair under#2I 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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (f.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii different(example-3©20200'and 2( 100)
10.Static water level below top of casing: / 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'
)
11.Borehole diameter:
t,' (in. 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a-i a' rOT4r Y1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) i 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
h (D IA/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I Method of test: j
13b.Disinfection type: � 1r 1 Amount:_4'Z l b
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