GW1--03420_Well Construction - GW1_20230516

—'` ;. •i,r v`i'�1 i—i= 1140 ; -14 M For,Internal Use Only:
•
, , i illi7 iN;I-lri•1, ,t, 1��,.:Ib {� ! ,Y.;rY
WINWATEA?ZONES.
-- — — -' RTnoM DESCRIPTION
- DISCPTION
-- -_ - - ' 779 io ft. qK! f• 5 6 PP1 C 1z Li t >~ r #) '�
' ; �j��_ l aa1 ft. Ico3 ft. 45 GSM Gie G ire-c»ttlh.cY 7
e.[_..r: C u$cationNumber 15.OUTER CASING(foruiulti-rased wens)ORLINER(if a nimble) F
FROM TO _DIAMETER TRICKINESS MATERIAL .4(-1AOt6N WELL COMPANY INC, ft ft in.
eempmyName` 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICICdE5S MATERIAL
Li Weti Cocable tion Permit#: D p �O ✓" /ft 1 o9 it in. ry 5/� ea, vN
c""
Lirt all applicable well construction permits(1,e.UIC,County,State,Variance,etc.) 44 l ��3.Well Use(check well use): R k in.
17.SCREEN
Water Supply Well: F{iOM TO DIAMETER SLOT SIZE THICKNESS MATERIAL fp `
❑Agricultlual OMunicipal/Public \ ft. \. ft. \ in. \ \
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) • \ft. \ft. \ in. \ \ '-":".f
DIndustrial/Commercial • Residential Water Supply(shared) 18.GROUT F
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT j
Non-Water Supply Well: 1) ft• r25 ft. j° Qh1)5 }Po
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVES,PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage \ ft.
\ ft. \
❑Experimental Technology ❑Subsidence Control \, ft. \ ft. \ \
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hnrdnestrsoiVrorooek type,groin sue,etc)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) DE / w: t g '
4.Date Well(s)Completed: 5-1-2Well1D# /9-5f01 1,, f• 19? ft- 9 fc()i e AlAY 0
6 W JM
5a.Well Location: Phone # 6 3 9"32 to to S
R ft 75 O)l I 1 J LU13
- �oh 1#u111h 4zt Infi:... `
►+J ft f 13 f ITT }��1� r,�� KLL'?'1 . • r. :5':•••:-:, 1 Ir:.
tY (ifapplicable) )la ft. 6 2L1 ft D,. IT /Cy 9 I dl �'t Oi -
Facility/OvmcrName Facility ID# a hcable �/
Gt g D ,-j p'rt. A9u-/t 4r T11/ 62 if ' I(lo3 ft. 114 !vim )t, ht sty amp- ,.K
Physical Address,City,and Zip Plitt 1 4111 t PC:, .1046 ft ft.
21.REMARKS
GlI lk{ r 3 l�.o cafe' 1a a Ga vat d i i,a /0
•
•
County Parcel Identification No.(PIN) c./ 40 ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 11-,Wt - , r tt.
(if well field,one lot/long is sufficient) • 22.Certification: ( • it)h fe /c/IOF. r
G 13, 145611 N 2?4/ 4erf, 7 5 _ w j 5,A-
6.Is(are)the well(s):,ermanent or ❑Temporary Signature of citified Well Contractor Date
By signingthisform,I hereby cerl(fjl that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes orIo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction informationapt
d explain the nature of the of this record has bens provided to the well owner.
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: [ 24.SUBMITTAL INSTRUCTIONS
/ S
9.Total well depth below land surface: 1 ao (ft') Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3@200'and 2©100�
�50—'� (ft.) 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
Ifwoler level is above casing,use"+" ''-- (in.) Bit Off: r7�.Ia S 29b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) •
11.Borehole diameter: �P Program,1636MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
PP�� fY Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) w® Method of test: �Y [/ � r, ij•
13b.Disinfection type: 70%HTH Amount: la oz DATE SITE VISITED: `�t 3 9` '�"1
I /� j=r='- ,i'll
r
VISITED BY: vP r-- Q Revised 6-6-2018
en..,,r.W-1 Cent of Environmental Quality-Division of Water Resources I