GW1--06929_Well Construction - GW1_20241119

•
•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: •
0-efFt e L -fit c/f ortGav%n .Jet-c-- SA r1 14 WATER-ZONES •:'<'.• .k.,:`
Well Contractor Na FROM TO DESCRIPTION
11 ° 6 : . h .
NC Well Contractor Certification Number ,
M / / ? 15 RI 3OUfECASING.(formulti tsedwells)'.OR'LINER(ifsp"livable)
:
2 L, , 7 .%/�"s w e( V i"l'G`/'n y .L FROM TO DIAMETER THICKNESS MATERIAL.
Company Name 1 f+ ft: /VOL ./ /4 rn. •,25 P v C
• p , =:16:INNER:CASING'OR TUBING(geothermalclosed-loop) _
2.Well Construction Permit#: -7 D� a 33 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perinits(Le.UIC,County,State,Variance.etc.) ft R. ' m•
a 3.Well Use(check well use): ft ft. 1 in.
Water Supply Well: 17--SCREEN -.}'. _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) giRrsidential Water Supply(single) ft rt. in.
❑Industrial/Commercial oResidential Water Supply(shared) 18::GROUT::. ... ,:
❑Irrigation ❑Wells>100,000 GPD ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft a 0 ft. 2? „1": iO .
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK'(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft II.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer • -20 DRILLING-LOG(attach addidanai sheets if necessary) . _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,bordoeu sell/rock type}cote size etc.) '
b ft ft. j '/f,. e C�
�/ ,`r�r� !�
4.Date Well(s)Completed:/0'"//da"/Well ID# a O it if
ft ; P-;Y- C,-1...-ce�
Well L cation: 4i ` �V t. tied'. p [ to/View ,
,� GD1 + A i-P ft
Facility/Owner Name Facility ID#(if applicable) ft.
----:':/ 0 Cen-/f/Ic�e'v c1 cerci 'Rd
ft. It. NOV 1 C�ZC+
I Address,City,add Zip / �p ft' ft
()Wail
cCC. 07 1 21:RE ft.• h . i, a 1
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 1�/, , 22.Certification:
&I
3S1 8-i fo N go 4 '1- ' /�/ W - �w /0 —�/—��
6.Is(are)the well(s): ermanent or ❑Temporary of fled Well Connector Dace
By signing this form,I hereby certify that the wells)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or ellg 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known 11411 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 wel
l ell details:
8.For GeoprobelDPT 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 a-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
Li (ft,)
For
Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
multiple wells list all depths if different(example-3@200'and 2@100)
1 S 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use +"
11.Borehole diameter: G /$ (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 16 P / 24c.For Water Supply and Op i n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,eta) county environmental health department of the county where installed
1`
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test: ! r i
13b.DIsinfection type: H. 7 Amount: ,3 jO i h -f
1