GW1--06935_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor In rmation: •
,e 1 V)✓i L k gemi., '2'1G "14'iWATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number
���J f, � �-�1S::OUTERiGASING:(fodm6lti�cnsed vi�eUs)ORIINER(Rim i1c961e)
G . j"f/" t t!!r j ) ( al/Y� l ll, - FROM TO DIAMETER ' THICKNESS MATERIAL
.4,.ill).
6 ft. .G �' in. e 5- pu c
Company Name 16..INNER.CASING OR=TUBINGlaitithermsl elosed=luop} ' ..
2.Well Construction j Construction-Permit -'i- ''f. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(cheek well use): ft. ft. in.
" Water Supply Well: 17:•SCREEN
PP YFROM TO DIAMETER SLOT SIZE THICKNESS ' MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.
OGeothermal(Heating/Cooling Supply) gaTridential Water Supply(single) ft. ft, is -
❑Industrial/Commercial ❑Residential Water Supply(shared) 18P GROUT. ... .. ,- _
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (?j it. 40 It heat-veil L' I bi':e44,-
❑Monitoring ❑Recovery ft. ft. j
Injection Well: ft. ft. i.
❑Aquifer Recharge • ❑Groundwater Remediation
::19i SAND/GRAVEL PACK'(if applicable) . .: ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer :,20.DRIL•LING`LOG'(attach;'Additional sheets it necessary). : ': .
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ' 0 ft. Jo R' 14 d C 1 A it
4.Date Well(s)Completed: f/"."'/Z'zy well ID# id ft- 30 ft- y&f JO N-S'� fileS 43 f e:
5a.Well Location: .z► To ft. cP /�1'pttil^ la,f>°�
•
/2.4lt ✓ (204-/ki:(-474 ��101�171 offf rr. try 't' �oIlt�.- ict-fe -
Facility/Owner Name 5 Facility ID#(if applicable) if , it. /ya it. / l i,...- :7! .�. ' a
��� ft. ft t•..� ::.. .�.,, w..
3q3 Z, �,%cCdle 1' ,
Physical Address,City,and Zip f �J O 9L4
W, ' • / !L 21 REMARKS
County Parcel Identification No.(PIN) (,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/llong is sufficient) 22.Certification: l
6.Is(are)the well(s): ermanent or OTemporary
Signature of Certified Well Contractor Date
/'" By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance-with
7.Is this a repair to an existing well: ❑Yes or ,I81Vo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repah;fill out known well construction h formation and explain the nature of the of this record has been provided to the well owner.
repair under RI remark section or on the back of this form. i
• 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!.GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: CJ /, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 0 , (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-36,20W and 2(411001
i 24a. For All Wells: Original!form to Division of Water Resources (DWR),
' 10.Static water level below top of casing: �2e) (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
r� " 24b.For Injection Wells:Copy;to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �/�/� (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4 lle go' It?V 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /00 Method of test: /¢i I
1
13b.Disinfection type: /7 j/J Amount: