GW1--06912_Well Construction - GW1_20241119

WELL L CONSTRNCTION RECORD(GW-1) For Internal Ise Only: '
1.Well Contmeter Information: .
/ xr„),-...... ,;„c...e. 14::WATERZONES i'
Well Contractor Name FROM TO DESCRIPTION
7b 36 . I qd it' ZSd rt
• ft. ft.
NC Well Conontractor Certificati� aNumber ) •15::OUTERCASING formulti-cased fells OR LINER
✓�G+ .may//rK�!is /. I [C/..1l /)vr a ( ..., ) (Ifs llcATEA: :..?;':; .:.
FROM 5.-O TO DIAMETER THICKNESS(I tab
RIAL
Company Name d T 1Aft q5 ft' 6 '/V m. ✓ 2.. e /v G
,.. i 16.INNER.CASSING:OR>TUBING:(>eother'mal-closed=loop) .:.:'%`::>' :`a;-
2.Well Construction.Permit#: /CC ( `/3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable yell construction perinits(i.e.UIC County.State,Variance,etc) ft. in.
3.Well Use(check well use): In.
Water Supply Well: 37:SCREEN.
FROM • TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft it, ' In.
❑Geothermal(Heating/Cooling Supply) (Bleesidential Water Supply(single) ft. I in. .
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation MATERIAL>100,000 GPD . FROM TO MATER EMPI4oCEMENT METHOD&AMOUNT
Non-Water Supply I Well: 0 ft. R. , I TL
❑Monitoring ❑Recovery ft. it.
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salim Barrier '19.SAND/GRAVEL'PACK'(ifnpplicable). -:.•-'::, -.::- ::::..;:.::.'..:
q g ty FROM TO ' MATERIAL EmPLACEwENrMETHon
- ❑Aquifer Test; ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft. !
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG:(attach oddidonnl sheets Ifnecessary)s;- .,:s•-7.s:.:i :::,:r.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEse ON(color.hardness son/reck type prism she ere)
// 9/) 0 ft. 50 ft. CAS
4.Date Well(s)Completed:f--/Jy' Z-5 Well ID# rj0 it 70 ft. ( /sa.a Z-/a4•G
•
5a.Well Location: ,:,I• 70 It' cf(J tt ,5j4.4,4 e
•j9o.ti)�l! /He-/-L- � qa /� �ye,..yt.) .
Facility/Owner Name "‘ Facility ID#(if applicable) q5 fL %f _
%.5o yP-eh 1- e>✓om c.-4-• ft. ft. ; 6` _a' '-- ..:,L
Physical Address,City,and Zip ft. ft.
/fiec.4i 4 5 . . %vq-3S� -y� `.
�✓) u✓ zratElt�ARlcs .=_=;:: :::::•,:. . ..,:fdQ;V:fit,..�.,tJ24:•
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O'`'' '`O3
(if well field,one let/long is sufficient) �Y e - 22.
Certification:er' z,l�/t�!'� �G� N tJ/ L��Z�� ! W /[�'4�®,,"`"J :e.......a,
� V"--'1 J 'Z'�
� Signature of Certified Well ontractor Date
6.Is(are)the well(s): D1Permanent or OTemporary
gn
__// By signing thisform.I hereby centiliter the wells)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or .3PIo 1SA NCAC 02C:0100 or 15A 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 remark section or on the back of this form. 23.Site diagram or additional well details:
' 8.For Geoprobe/DPT or nosed-Loop Geothermal Wells having the same You may use the back oft is 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 (ft.) I Submit this GW-1 within 30 lays of well completion per the following:
For multiple wells list all depths ifdiferent(example-3Q200'and 2©100')
t0.Static water level below top of casing: ( ) 24a. For All Wells: Original' form to Division of Water Resources (DWR),
f Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing.use"+)
11.Borehole diameter:•
�� (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /t'.ri?a�-y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) Q county environmental health department of the county where installed
1
N. FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
{�i;+t,, A Permit Program,1611 MSC,Raleigh,NC 27699-1611
k. . f7 13a.Yield(gpm) -. l , Method of test Air" !
13b.Disinfection type: 77-1• Amount: 3 14Tf 1 '