GW1--07655_Well Construction - GW1_20231204

yr.EJ ai i‘..Ul®I►7 I ECU IL.H RUIN 1CL'L P1tIJ(i i W-1 I For Internal Use Only: ; '
1.Well Contractor Information:
' TeFfrey /. !�'e r / /3 c a .r i /2"'C� 14r'WATER ZONES •. i =:
Well Contractor Na FROM TO DESCRIPTION
�lC�ai� ft., ft. 910 lie, 155 Lg5
ft. ft.
NC Well Contractor Certification Number • 15.OUTER CASING`(for multi-cured wells)•OR LINER(if in"livable) '
FROM TO DIAMETER THICKNESS MATERIAL
�L (U1t,'5 - U�et ) 1t1(
Company Name n / ft.„So ft. ��4J in. iLo2 11v�
��y� pL :,16:INNER:CAS1NG OR TUBING-(g(eJothermal closed-loop) /
2.Well Construction Permit#: 31 ' ►th 3)j� n -3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in.
• Water Supply Well: 1.T SCREEN
+ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural OMunicipal/Public it, ft. 1,in.
❑Geothermal(Heating/Cooling Supply) ,esidential Water Supply(single) i, ;in,
❑Industrial/Comntercial esidential Water Supply(shared) 18:GROU
❑Irrigation °Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. So ft.
❑Monitoring °Recovery f. ft. �u d
Injection Well: ft
°Aquifer Recharge °Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable).::: ._- : - _
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test ❑Stormwater Drainage ft. ft. I
❑Experimental Technology ❑Subsidence Control ft. ft.
i.
°Geothermal(Closed Loop) °Tracer 20:DRILLING LOG(attach additional sheets'ifnecessaty)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sollroctctype grain sae etc.) '
J ft. rt,
4.Date Well(s)Completed:/ -3-o23 Well ID# a D ft. e ft. j4W1.1�J-�
5a.Well Location: 3 D ft. 6 aft. Bt , 6.k /p.ie-
• Rnt\ U-vt-)\1.i i',-,nn;S 50 ft. 2 e o't 1.4,e 6.,,,- -.
Facility/Owner Name Facility ID#(if applicable) ft. ft. I.
;a4,b ,cu k t P ci ta ,ran O Utl Kto, ft. ft. - . : , � _�
Physical Address,City,and Zip r�('� ft. ft.
re "e
I`ih�I 10
� 1 0� )�� 2L REMARK$;: .;' [ ('_9 i 2 Ct a3
County • Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r"."." -9'_
(if well field,one lat/tong is sufficient) 22.Certification:
.35 t 5e, $/3 N &9 0 1Sa 66 W
1/-3 -.23
6.Is(are)the well(s): iZticmanent or °Temporary of C ed Well Contractor s� Date
/ By signing this form,Thereby certify that the well(s)was(were)constructed in accordance•with
7.Is this a repair to an existing well: ❑Yes or O ISA NCAC 02C.0100 or ISA NCAC!02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction Information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 rernarla 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�W-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: 2 O 0 (ft.) t
For multiple wells list all depths if different(example-3Q200'and 2Q100')
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original 1form to Division of Water Resources (DWR),
10.Static water level below top of casing: t . o (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
a If water level is above casing,use"+"
11.Borehole diameter: 4,2' (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,N'C 27699-1636
12.Well construction method: /�d�4 r t/ 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
in I r, Permit Program,1611 MSC,Raleigh,NC 27699-1611
C ' �
13a.Yield(gpm) ,3 Method of test: fit I
1/'
13b.Disinfection type: r I Amount: /rill 1 "