GW1--06934_Well Construction - GW1_20231027

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
amid" 1hezio/1'L- 1Lfa4 a.IS Rat_ 14.WATER ZONES•
Well CoauactorName; g 372-/5/ C. 7e9 G FROM TO DESCRIPTION
ft
AC97,2- "#''397:{Ci n ft. I j
NC Well Contractor CeRifitationNamber 15.OUTER CASING(for multi-cased wells)OR LINER(if a le)
/t �J Gr4 �_ }_ /�i X ,p� FROM TO DIAMETER THICKNESS MATERIAL
l�r/ �r�L�! JV / g, n - -
Company Name
- - I.
``,,Iy ,{ 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permft#: 7/ t/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Varimue.etc) -/./ ft- 7a IL .9 m' 3Gh die P Yc_.-
3.Well Use(check well use): 75 ft. 'j'7 ft. dF: in- Seh.,y' e t/e.,_
Water Supply Welk .. 17.SCREEN
FROM TO DIAMETER SLOT SIPR THICKNESS -MATERIAL
['Agricultural ❑Mmicipal/Pubiic 7 ZS ft: Tin. 40 ,T/ 5
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. I In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation. r ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • - d ft. 2/ IL Nae P4. A" -'- •
❑Monitoring ❑Recovery ft. ' . - ft. t
Injection Well: n
❑Agmfer Recharge ❑Groundwater RemedlatioII• 19.SANDIGRAVEI.PACK Of applicable)
❑Aquifer Storage andRecover), ❑Salinity Barrier . FROM TO, . . MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage &,/ it 77 ft• 1/rad.ee AriCA-
❑Experimental Technology . . ['Subsidence Control-- ft. ft. I.1
❑Geothermal(C1oSed Loop) ' . . ❑Tracer 20.1DRRLING LOG(attach additionalaheets if neeeeary)•. -
❑Geothermal(Heating/Cooling Return) •❑Other(explain under#21'Reinarks) FROM TO DESCRIPTION(color,bantam.sodlhaelttspe.grata size.ere)
' O R .. .2 ft... jQ
4.Date Well(s)Completed;.-/0-//'13 Well ID# - 3 ft- e5" ft: .(i/.eeF .
,�A OJ .
5a.Well Location: / ' ' •,5-' ft.. -".2U ft. 'et. . • ' ' ,...I. _.
•
•
<�i1vx-eL. SZSlYt .. . : •- : 07 D ft 10 Yee 4JtQ f- ee4T
Facibty/Owner Name .• '- FaciiityID#(if applicable) . 34" . . /(I. 644z.PG. Ae4d11 , ,
%u`"ep'eAtasSsi-- 7t�.ud"c'x.aa.-;:?'iG .2,73y� isR' "-8S'ft-, `/z:sid-
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Phy
ysi
iccalAddress,City,and Zip tt I, ' .
i /01:1 LPG • i.ek., tmo-2 g.ZS/ •
SLREMABKS r.. "- ,... '
County , . Parcel Identification No.(PIN) ` " 1t/ z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Q C T 2 7 202'
oifwell field,one Lit/long is sufficient) Certification: 4 g 9A-$ . T1 3178 G
22.
3. /4"y� N 77 P8W ', / R, �n,�, r, �lr.- :�•x 1 1,'�;;
Auttet'Adawix_. 41_,Oktat„-- 7iiiizli-P6•623
6.Is(are)the well(s):,QPermanent or ❑Temporary Sigma ure 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 ONo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out lnowm well construction information and explain the nature of the ofthis 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 well details: •
You may
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same use the back of this page to provide additional well construction info
construction,only 1 GW4 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attachadditional pages if necessary.
drilled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: . 7 7 - (ft.) •
For multiple Wells list all depths IOU:Teresa(example-3@200`and 2(0100) Submit this GW-1 within 30 do's of well completion per the following:'
�� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10-Static waster level below top of casing: (ft-_) Information Processing Unit,1617 MSC,Raleigh,NC 27699,1617 ----
Ifwater level is above casing-use"+" - - .
11.Borehole diameter: (m,) •
•24b.For Injection Welts:Copy to,DWR,Undergrwind:Injection Control(TUC)
• --- -• • •• • - Program;1636 MSC,Raleigh,Ac NCt 27699-1636 _ _
12.Well construction method: •t rtLLLI. (�t Q�:li,� - . L - •.
- (i.C.anger,rotary,cable,direct gash,ere) (� 24�Far Water Supply and Opeo-Loop GeotirerIDal Retnrn'V6ells:Copy to the
county environmental health department of the countywhere installed . ;
FOR WATER SUPPLY WELLS ONLY: 24d.For.Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13e.Yield.(gpin) l d- . •Method of test: .:�0lehil i] •Permit Program,`1611 MSC,Raleigh,NC 27699-1611
• 13b.Disinfection type: P�ES ' Amount: la., ('1)- -
Font GW-1 North Carolina Department of Environmental Quality'Division of WatcResouice j - - . Revised 6-6-2018