GW1--07224_Well Construction - GW1_20231108

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
M LP beii)0.41_ Q/Y Lc 4,4a.Aa4,4_, 14:WATERZONES I
Well Contractor Name FROM TO. DESCRIPTION
a 7/- 39 z8-e. AO ft. -SO �` � N5.
6 a "
90-
NC Well Contractor Certifi/cazioallombAer ��,�j /� IS.OUTER CASING(form i iaased wells)OR rdsp - ble)
/ t_ e gie v/ r ✓O /� FROM TO fL. DIAMETER THICKNESS MATERIAL
Company Name Iq/ Q� �(
JJ,, 16.INNER CASING OR TUBING(geothermal dosed-loop)
T 2.Well Construction Permit#: / eP/� FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) -II It. Q C 1/ i 1n. sr ye Pile-
3.Well Use(check well use): 74""it. g7 it. 4 I- in' S4C tf.O r d�
Water Supply Well: - 17.SCREEN I'
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural Municipal/Public d0 (t, . 9/n +5 ill,- 6 6' i(d.�i 5
❑Geothermal(Heating/Cooling Supply). Jesidential Water Supply(single) 7 c�
ft. it In-
1.
❑Industrial/Commercial ❑Residential Wafer Supply(shared) 18.GRooT I. '
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I B- .2/ ti/ - Nab �l/, � ,
Monitoring • ❑Recovery ft. ft. ""�
Injection Well: •
❑Aquifer Recharge roundwater Remediations ❑G _ "`J
❑A Storageand Rticove OSaliuit Barrier 19-SAND/GRAVEL PACK(f applicable)
guifer Recovery Y FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage 62/ L Ctrn At 4 Alk..4..
❑Experimental Technology ❑Subsidence Control IL IL
I
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional'sheets if necessary) .
FROM TO DESCRIPTION(color,hardness,wNrock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 n .2 O ft -t d! Ja L.//
4.Date Wells)Completed:16/0/3/23_ Well ID# Rd n' air jetiel
Sa.Well Location: 4(f t 45- tt.• „pi { -
£l!a7a;,t.2t; ,RIiy _ .lrft. too HCliral'. . ,4.4
• clhity/Owner Name' FaciilityID#(if applicable). 0.ft'. 10 5ft ' ,(„I._ ,/ •
A/D` k 0 NC... 4Sft- i io ft. PriA:02 ✓kt4d--ci 61u, ,
Physical Address,City,and Zip 2S'3/S s.: rr: w; .:w:..,•._ V - ,{ ) -
inQae gl"-t%*/ 2L REMARKS n1+ V v (�
- County ParcelIdeatfiicationNo.(PIN) �`��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' m:; :,,:/=+��? F.;�z:v,!...
(rfwall field,one lat/long is sufficient) 22.Certification:3372 #9- ' ' 39 7e- `13
rlscct97'51° N Y9 's5/ r 32, • W
0,0p1:11--.J tka.c.c=e;y0liaki---/67,06/2,x_
6.Is(are)the well(s):.OPermanent or ❑Temporary signature of Certified well Contractor V Date.
By signing th,sform.I hereby cert thai the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: _ ❑Yes or- ONo- 1SANCAC 02C.0100 or15ANCAC 02C.0200 Well Construction Standards and that a copy
If this is arppair.fill out known well construction information and explain the nature of the ofthis record has been provided to the wel/owner.
repair under ii21 remarks section or on the back of thisform. 23.Site diagram or additional well details
-8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may rise 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 Ovef in Remarks Box).You may also attach additional pages if necessary.
:_ drilled . 24.SUBMITTAL INSTRUCTIONS :
`9.-Total well depth below land surface:. Cl F (IL) P
-For multiple wells list all depths ifdifereat(example-3Q200'and 2@100) Submit this GW-1 within 30 days or well completion per the following:
I• I
level below top of casing: ( 24a. For All Wells: Original OM to Division of Water Resources (DWR),
10.Static water �/ ft) Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
Ifwater level is above casing use"+" •
11.Borehole diameter: -y @) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, MSC,Raleigh;NC 27699-1636
12.Well construction method: • `Yj 24c.For Water Supply and Ope-I oop Geothermal Return Wells:Copy to the
(i.e.anger,;Mary,cable,direct push,etc) county environmental health department of the county where installed'
•
FOR WATER SUPPLY WELLS ONLY: �' t
24d-For Water Wells prodncin�over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /'5/ Method of test: ,/"t/`J Permit Program,1611'MSC,Raletgh,!I�1C 27�99-1611
-
{
13b.Disinfection type: .WIUS2- Amount: /l.2/9d -
.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 6-6-2018