GW1--07858_Well Construction - GW1_20231205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
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1.Well Contractor Information:
JeFFre 2 /fpr _/��',•Q� //'/C '14"WATER 20NES - k
Well ContractorNa FROM TO DESCRIPTION
ft., ft.
NC Well Contractor Certification Number 15::OUTER•CASING(for''multi-ct sed:well4OR LINER(if ap pliable)
+ FROM TO ' DIAMETER ' THICKNESS MATERIAL
I.,, /YJul/� w�!/ fir, C!,r n0, ,74 / ft. i f& ft. 4 ,r .. e lot 5 pvc
Company Name ..
�16:INNER;CASINGiORTUBING:(geotherioelclosed400p).
2.Well Construction Permit it: . �� — 0R1.7 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perinits(i.e.UIC,Count,State,Variance,etc.) It. ft i in.
3.Well Use(check well use): ft ft 1in.r
` Water Supply Well: 17:SCREEN :;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�Municipal/Public ft. ft. 'in.
❑Geothermal(Heating/Cooling Supply) IHResidential Water Supply(single) ft ft in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) :'18:GROUT.
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft of�1Q ft.
-,a-- e2�c�d
❑Monitoring ❑Recovery ft ft. �GlyL� ``�
Injection Well: '
❑Aquifer Recharge ❑Groundwater Remediation tt, ft.
19.SAND/GRAVEL":PACK(if applicable)" .
❑Aquifer Storage and Recovery ❑Salinity Ranier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft, ft
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❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer `;20s"DRILLING :OG(attach addittdnalsticett ifnecessaky) _ ...-
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM To DESCRrr'TION(color,hardness soillioektype grain size.etc.)
0 ft a0 ft. JAel/ ..5Y-e)n,e
4.Date Well(s)Completed:!0-.9-5" ell ID# a 0 ft C/6 ft fz,...t.,€, St%
Sa.Well Loca'°II II& ft' L/yOft. 'et-tea ,/! �
� . "A©�IVIA1 H In ft. ft. •
Facility/Owner Name Facility ID#(if applicable) ft ft. ' 1--j (f m,V F.:D
6 90 '7 Letrl ece si'w iiwf ft. ft. DEC 0202�
Physical Address,City,and Zip
D335OD� z1RErARKs Li/1 ;oh 611.r .� : a :tiK
County Parcel Identification No.(PIN) DA OfBOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) � 22.Certification: •
3'el, 3`i y'/ N S //.J� �y O, (� /.2 W
/�^^ � Wei /;�- as �3
ii&6.Is(are)the well(s): Ef ermanent or ❑Temporary of ified Well Contractor Date
By signing this form,Iherebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Fptco 15A NCAC 02C.0100 or ISA NCACIO2C.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 remarks 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 1iW-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: 14110 (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(g200'and 2®100)
10.Static water level below top of casing: 3 S(>'� (fL) 24a. For All Wells: Original!form to Division of Water Resources (DWR),
If water level is above casing,use
o Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: /$ (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
kD1a 12.Well construction method: / c 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producr ig;over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) '. Method of tests tl f
r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:)T T hi Amount:,.f/1 f3