GW1--06913_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i '
1.Wel C ntractor In rmation:
14`WATER-ZONES :.:•, i•.:' .-:'.:',''.:-..-1.,' : ;: :: ;i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC.We1l/Contractor Certification umber / : s.:OiTfERCASING'.(for Multi-cased ivells)'OR�I INER(Wan l(cable)
V \l t 'A 1 4 1 z q.11)( A 1 �/ r t
FROM TOOK DIAMETER THICKNESS R.L`�'�J V wl� V� Vl Oft. /0 fL i % n. s Zd� i M >Pr�e'A
Company Name
7 :16;INNER'CASINGOR>TUBING:(geothermal'dosed=loop); :<:_.-::: =
2.Well Construction Permit#: IC) I 1 2,(0 FROM TO DIAMETERTHICKNESS MATERIAL,
List all applicable well construction permits(Le.1VIC,Count, tate,Variance,etc.) ft 22.....
� ft ei in. . 25e) PVC
4 3.Well Use(check well use): rrt. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. . ft. in.
❑Geothermal(Heating/Cooling Supply) r atrial Water Supply(single) it: ft. in. ,
['Industrial/Commercial ❑Residential Water Supply(shared)
['Irrigation ❑Wells>100,000 GPD • FRON TO MA,VRIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft /2ft' ,i Lij: , 112..
['Monitoring ['Recovery ft. ft 6
Injection Well:
❑Aquifer Recharge • ❑Groundwater Remediation ft ft.
:19.SAND/GRAVEL PACIC(if applleabie)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage R• ft-
❑Experimental Technology ❑Subsidence Control ft ft
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOOG(attachradditional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRn7ION(rotor,hardness sorUrotic type grain alze etc.) ^
ft it.
4.4.Date Well(s)Completed:9 ' Well ID# ft. ft.
5aj.Well Location: , f. ft. •
J > :
Facility/Owner Name `-- Facil' ID#(ifa licable) ft ft. :. . '?•:..': '` `'""'_
9Z�Z ) 1u4A 1 l • ( Lir (2J it. f. NOV 1 6) [0[4
Physical Address,City,and Zip ft ft
i1\4416 AL-1 • 137 - 121-05 _.
2l:REMARKS;: _�::_IrF c...�
County J Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer u ii 1 n,:
N W 1.�� / /' _. 9/3aill
6.Is(are)the well(s): a .--nt or ❑Temporary Signs emified Co or Date
By signing this form,I hereby cert10 that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: es or ItNo 15A NCAC 02C.0100 or ISA NCACB2C.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 dt1 well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional�vep 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: _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �-� (ft-) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') yP
I 30 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
filmier level is above casing,usee"+" L L
7 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 43 A
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1/t I ( n 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) J 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) )I';y Method of test: j 7-/, Permit Program,1611 MSC,Raleigh,NC 27699-1611 ,
13b.Disinfection type: fZ! IT Amount: 17/4.