GW1--07632_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i •
1.Well ntractor(Information:. 6-,1
(/ i( 1 E L1 (1 3 ti yin 3eJ K. a wATERzortEs {
Well Contractor Name FROM TO DESCRIPTION
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ft•' 10
NC Well Contractor 'ficationNumber i
J [rI !S U)C
I ! \I I lT S:;OUTERCASING(formulti-METEwelts)'ORI '�np'itcable)`•.:;:::; "'::
Clt ,�tJ^t FROM TO DIAMETER THICKNESS(f MATERIAL�//
Company Name ^ i•� Q ft. 21 ft. ( t L m. t i L I Pv c
I � � / [� r16 INNER:CASINGORTUBING:(geotberinel clesed400p)
2.Well Construction-Permit#: `� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
< 3.Well Use(check well use): ft ft i; in.
Water Supply Well: 17.SGREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1 Residential Water Supply(single) ft, ft. in. -
❑Industrial/Commercial ❑``Residential Water Supply(shared) i8.GROUT
❑Irrigation ❑Wells>100,000GPD . FROM TO MATERIAL EMPLACEMENTME•TR &AMOUNT
Non-Water Supply Well: it. ft. f
[Monitoring ['Recovery ft. ft. en
Injection �( I ►-�
Injection Well:
ft. ft.
DAquifer Recharge OGroundwater Remediation
-.19:SAND/GRAVEL'PACK Cf applicable)=.::: :�..:.,;:::::. .: ;:';-: ^.:.:
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
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['Experimental Technology ❑Subsidence Control ft. ft. ;.
❑Geothermal(Closed Loop) OTracer '20i'DRILLINGPLOG:(attach additional sheets if necessary) . .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soil/rock type grain size.ere)+
1�1 Z3 ft c�ft. a- c�
4.Date Well(s)Completed:I� Well ID# C)ft ( () ft ;)-)f=
5 ,Well Location: :,i S Q ft. t5ft. ��
IA'
Facility�Owner Name FacilityID# a applicable) ft �1 � � � ,,�^
(ifPP ) �� � 1
ft. . ft. �r l r ,
Physical Address,City,an Zip it. ft.
ext+rl u3b 0._, C�ti, 1 4 1L L O 21.'REIC7ARICS:' 4 .'e 1� 3�k u):
County Parcel Identification No.(PIN)
` 211,E
5b.Latitude and longitude in d DEC
/ 'g1 agrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) l f; i vr�_, ,,.
22.C •nation• = . .- .. ice;•;a
(9. L� 18 N 19tc3391 W . �..:i _,;;� '
jdir) 3
6.Is(are)the well(s): f ti ermanent or ❑Temporary S atu e of ertified Well Contractor Date
By sign tg this form,I hereby certify that the well(a)was(were)constructed in accordancewith
7.Is this a repair to an existing well: ❑Yes or ANo 15A N AC 02C.0100 or 15A NCAC�02C.0200 Well Construction Standards and that a copy
If this is a repair fill out known well construction information axplain the nature of the of this record has been provided to the Well owner.
, repair under#21 renrar iw section or on the back of this form. i
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
9.Total well depth below land surface: -3a0 (ft.)
For multiple wells list all depths ifdifferent(example-3(4)200'and 2©100) Submit this GW-1 within 30 d i ys of well completion per the following:
10.Static water level below top of casing: f, 24a. For All Wells: Original I form to Division of Water Resources (DWR),
• I0.Static
tar tevel is above casing,use op" ,(( �O ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 'Ib l I 1 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Ai(' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1'it Amount:_
1
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