GW1--06940_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(OW-1) For Internal Use Only: I .
1.Well Contractor Information:
ILely 1 VS 3e11c , . r CA(.. (_ (-) .' . -
'`14:WATER ZONES::=.
Well Contractor Name FROM TO DESCRIPTION '
2o S , 26 ' ft.
NC Well Contractor Certification Number P
15::OUTER CASING(for:ntdavased4ells1ORL INER(iiap"liable)
pL o f`\%S Weil
l 1 1 ‘1 1�5' FROM' TO DIAM THICKNESS MATERIAL
Company Name vv 1 ,J ,�I it b Li ft. / ri, y in. r� P,0
V c C
•16:•INNER,CASING:OR-TURING(geotherinandosed loop) .
2.Well Construction Permit#: _// FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernilis(i.e.UIC, ounty,State,Variance.etc.) ft. ft. j, in.
.. 3.Well Use(check well use): ft. ft. In.
Water Supply Well: l7sCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft ln.,
❑Geothermal(Heating/Cooling Supply) Caftfsidential Water Supply(single) ft. ft. ia, •
❑Industrial/Commercial ❑Residential Water Supply(shared)
:18,GROUT:: : .
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERiALS silKAZatEc ii-te'imAitort&AMOUNT
Non-Water Supply Well: D it
2O it
�"
❑Monitoring ❑Recovery ft. ft:
Injection Well: o
❑Aquifer Recharge OGroundwater Remediation ft. ft. I
❑A uifer Storageand Recovery :19.:SAND/GRAVEL PACK'(ifapplicable),
q ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test i ❑Stormwater Drainage R. ft. !
❑Experimental Technology ❑Subsidence Control ft. ft. 1
°Geothermal(Closed Loop) ❑Tracer ':20:DRILLING LOG additional sheets if necessary) ' :.it
❑Geothermal(Heating/Cooling Return)
r� ]❑( Well ID#Other(explain under#21 Remarks) FROM To DESCRIPTION(color.lwrdoess aolUrocrs type pain size eta)
• O �IU'to 1 .0 it.
I D it.
r-e - Gi��
4.Date Wel(s)Completed: it,
- ft. 5-0 ft. Se rtc(c��Q
Sa.Well Location: •.t SO it. f'4 ft. b`.)e.- 9r AA t
14,6X4Ok) VP D ii_. se.- gy ft 300 it . li
Facility/Owner Name 11 �, Facility
IID#�(if applicable) fL I
fv
Physical Address,City,and Zip ft. fL �,_.
air 1 .c l p • o5--/70,_ooz/ 21 1EMARKS,. ..'- ir_ 'is/OV-4 _f-20/4 ..
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:
'1!k ' N gO4 77/ 7 C w
,d,4ir-7/1 -ge,i")6.Is(are)the well(s): l rmanent or ❑Tern or r Date �- 4
( p m y Signature of Certified Well Connector
By signing this form,I hereby certfp that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or No 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair fill out known well construction information m d erplain the nature of the of this record has been provided to the well ottmer.
, repair under#21 remarks 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 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:•
024.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 0
For multiple wells list all depths ifdierent(example-3Q200'and 2QI00) (ft) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" i (ILI Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: I.
1.. (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
kiiProgram,1636 MSC,Raleigh,NC 27699-1636
12.Well coon method: cis lc,
24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the
(i.e.auger, .,ble,direct push,etc.) py
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) 7 / /� Method of test: 2�� L Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: A! 7"/i Amount: J <`J7 S
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