GW1--06436_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contra Is
14 lVATERZONES, t 9-
Well Contractor Name FROM TO D&SCRIPTIO
/y a ft. 5`` ft i
7 �-ef /674rft 0 ft. 1
NC Well Co,�nt tor C 7 ication Number AS::01.1TER`CASING(forinultr-cased i'elis)`OR•.1INER(dais licable)F
,� FROM TO DIAMETER THICKNESS MATERIAL
ff/,!� eat 4 ,A , 4. l'a, 42 ft f p/ t In'Name
/d% �G f�v �/I�m
..46'INNER'CASING".OR'TUBING"fgeothennaa:closed-loop):. 4•:
2.Well Construction Permit it: 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): ft. ft in.
Water Supply Well: a17:SCREEA. t ,< . ,i:
'
FROM TO DIAMIcL5Et' SLOT SIZE THICKNESS MATERIAL
Agricultural Bcipal/Public Ar''5 t. /,/�ft in I f2 0 544
9
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft /d ft. in.' �"
Industrial/Commercial °Residential Water Supply(shared)
;18I.GROUT .".::'. _ ,-':I6' .. 1;:= t'= ,:,,;,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-- Non-Water Supply Well: - -- - - " --- --- — - - --0- ft --go ft /S,4 y�e.1 --- •�/t-7a 1,_ -- -
Monitoring Recovery ft. ft. /�` /
Injection Well:
ft. ft.
Aquifer Recharge ' oundwater Remediation ;19:-SAND/GRAVEL PACK'Ofappllcable)
Aquifer Storage and Recovery QSalinity Bather FROM TO MAT EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage /0.Y
ft f/O ft.
j ,944/ 0,,,,'"
Experimental Technolo F if Subsidence Control ft. ft
Geothermal(Clos-• oop) `I'Tracer t 20::DRILLING I.OG(attaeli*iulditionursheets if necessary}-;::. . C, :) ;:
Geothermal FROM TO DESCRIPTION(color,hardness,seRrrock type,grain size.etc.)
(H-:ting/Cooling Return) •��they(explain under e l Remarks)
4.Date Well(s)Completed: Well ID# ft. ft. G7 ' 4.-` ' V '4;, ?.,
5a.Well Loc on: 07t,-' • c4.:.) ft , Nov 0 i 2074
��
t tLcJto\'(' OV) ft ft. _ ,� .. •.. .
Facility/Owner Name Facility Mt/(if applicable) / ft i/f ft 4 �a r.r.. -- '�-
1 o a-$ Vag. Pk k- tit/gig , �0 ft �
Physical Address,City,and Zipigtep
9 j i O ^21:REMARKS . ,. :N,L' .: f .,
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 - (j�� ,ry`- /0/R `/t
6.Is(are)the well(s) rmanent or Temporary Signature of rtified Well Contractor Date
By signinng this form,1 hereby certify that the wells)was(were)constructed in accordance
' 7.Is this a repair to an existing well: DYes or Elie with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and drat a
Iftlhis is a repair,fill out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair bander#21 remark 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: ACIC) (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100') construction to the following: 1
te
10.Static water level below top of casing: !/ (ft.) Division of Water Resources,Information Processing Unit,
.fwater level is above casing use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
GI�J,�r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /PY4 3 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,/s/ Method of test: ��.4/ 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit;one copy of this form within 30 days of
13b.Disinfection type: ( 4iai-f Amount: oe0 completion of well construction to,the county health department of the county
where constructed: -