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Home My WebLink AboutGW1--05097_Well Construction - GW1_20230804 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: nn n � � (� VQt� t 1 1U, GleAJ I4.WVATERZONES I Well Contractor Name FROM TO •---_._DESCRIPTION t 7rS—rL I . rL o2,0 •191-1-N 35th a_ n. NC Well Contractor Certification Number 15_OUTER CASING(for multi-cased w'elLs)OR LINER(if ap livable) t T \ \ FR M TO nr..I THICKNESS :MATERIAL 4-01skl-I'S .ell c1J(r111 K3 `vl� . it i n tY m,� r(/.'�� V'( Company Name �] ?f c - c�1-1 V. t`11t� 16.MITER CASING OR TUBING(geothermal closed-lollp) -c-:•1 2.Well Constructon.Permit:4: 3% 2' Lk 23 FROM TO DL4MP.MI.R i THICKNESS I 31ATERLiL ' list all applicable well construction perm.its(i.e WC.County.State.Variance.etc.) fit• ft. in. 3.Well Use(check well use): fit_ B_ in. SCRE N Water Supply Well: FROM E TO / I DIAMETER SLOT SIZE THICKNESS MATERLLI.-- ❑Agricultural ❑NIunicipal/Public f_ It. in. ❑Geodtcnnal(Ileatin(Cooling 'Supply) Rcsidential Water Supply(single) R. ft. in. I 1 ❑Industrial/Commercial ❑Residential Water Supply(shared) I8_GROUT I ❑Irrigation ❑Wells>100,000 GPO FROM TO MATERIALL EMPL\CENIENTMETHOD&AMOUNT Non-Water Supply Well: 0 ft- 3 ft• 0-mey_si �lth ppL� nr * ❑Rccovcr}• 3 ft_ �0 rt- )..e t —t --�� \ n Injection Well: I y��n(-r PL� fr.. It. ❑Aquifer Recharge ❑Groundwater Remcdiation 19_SAND/GRAVEL PACK(if applicable) ---- f7Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPL\CE.MENTMETHIOD ❑Aquifer Test ❑Stonwater Drainage 1 R. fit. i r ❑Experimental Technology ❑Subsidence Control It. ft- ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) ' ❑Geothermal(HeatineICoolina Return) UOther(explain under°21 Remarks)" FROM rat DESCRIPTION(rotor mess soi0ra`k type.grain size.etc.) _. rr. n. 4.Date Well(s)Completed: 07/05 0.-3- Well iT �3s•ay,23- - 4-0 rt 0 .It- .-�,-6� , -741 �eck, 3a.Well Location: r c3 G fit p fit . S g �`��(}`tee+I �•Y c�f�l f�- •. • • r� O V `J 1 L J c tt•S1 o vr, �o mi�S rt. rt: Facility/OtvnerNariae' . . ...Facility IDii(if applicable) 'R- : ' II- ' - . l.,:c ,.'-y'. E,j \J t—r . . 1 •1a 05 'Pond S41,�.7( 'r) Cre_e ,coy) t� A13-2,� �t: n. Physical Address,City.and Zip - rfit ft. N U U V II L U L 3 GV`ai1V\llt; 1 C2 I9-00 si-3b �.3(p 21.REMARKS. U County Parcel Identification No.(PIN) DIAI01 .G —1 Sb.Latitude and longitude-in degreeslminntes/secondsor decimal degrees: 1 (if well field,one Iat/long is sufficient) 22.Ce [cation '310.. n3 elgG iN 1gS. 3(0 'Z 7 w ` i C (4,090qoa_' 0�4y 6.Is(are)the well(s): t 'ermanent or 17item orar}• .. Signature oI iGed\fell .ontracaor , . D I lay signing thisJornn,1 hereby certif.—Yawl the well(s)was(n•ere)constructed in accordance nitb 7.Is this a repair to an existing well: ❑Yes or 'No I i.1 NC.IC 02C.0100 or 15.4 NCAC(DC.0200 Well Construction Standards and that a copy If this is a repair.fill out biotin well construction information any!explain the nature of the 4l'this record has been provided to the well Gem,: repair under ii21 remarks section or on the hack of this farm - 23_Site diagram or additional well details: - S.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. dolled: / 24 SUBMITTAL INSTRUCTIONS _ 9.Total well depth below land surface: i S. t :. For multiple wells list all depths if different(example-..3.W00.rn{rl?fill{on') (fi ) Submit this GW I oithin30 days of well completion per the following: 10.Static water level below top of rasing: a(? . . 24a. For All Wells: Original form to Division of Water Resources.(D\4R), (fit-) Tnfomntion Processing'Unit,1617 MSC,Raleigh.NC 2 7b9.9-IbIJ 1 water.._ _.tc!..ahataoQci:{� tr-ce" - i i.Borehole diameter: (o (in,) 24b.For Injection Wells:Copy-to DWR.Underground-injection Control(IUC) Program.1636 MSC,Raleigh,NC 27699-1636 ' l p I2_Well construction method: .. i ► 24c For Water Supply and Open-Loop Geothermal Return Yells:Copy to the (i.e.auger,rotary,cable direct push etc.) county environmental health department of the county where installed • FOR WATER SUPPLY WELLS Oi\rLlr: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA. nn Permit Program,161 I MSC.Raleigh.NC 27699-1611 l3a.Yield(gpm) a 0 Method of test: V.I q, 13b.Disinfection type: l�CYVr( p_L Amount: b 02- Font,GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S