GW1--07859_Well Construction - GW1_20231205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
S�eFFre�t. 7 ke r't _� . ►^ /8 ,u h>7 Pam/C t° I4.•WATER ZONES.:`:- _ : _
Well Contractor MimePROM TO DESCRIPTION
/'� t� ft. ft. /30 ,2 yS� .2751 .2 9v
'/. &e oC ... ft.' ft
•
NC Well Contractor Certification Number -
15..OUTER CASING"(for multi-cased:wellsyOR LINER(Rap"Ifcable) _ --.-:_
r r t FROM ' TO DIAMETER THICKNESS MATERIAL
V, 4, /h k 1/i S Gf/P// V!'r el.7, ,L ✓1/C + I ft. IS rt. g it . f/15 PI/G
Company Name
/� 16INNER.CASING:OR'::TUBIPIG;(geotberiivalclosed=loop) ;- ::-
2.Well Construction Permit#: . OK 3 -• ,2 V e 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. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MMu�iunicipal/Public It. ft. 'In.
❑Geothermal(Heating/Cooling Supply) If'1Resdential Water Supply(single) ft. ft. 'in. -
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT < .
❑Irrigation ❑Wells>100,000GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. o2 a ft. 93 .17Y„a„, p.1,4 c c/
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge 1 ❑Groundwater Remediation
:19i SAND/GRAVEDPACK(if applicable)" _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20 DRILLING:LOG'(attach ndditionalsheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rocktype.grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ip ft. / G ft. -ij i/ld e tJ C (.../1
4.Date Well(s)Completed: /0$11-1- Well ID# / ? ft. '1.j ft. �[u e ,'Za�9 0
5a.Well Location: - 113 ft. ,j 0l5' 7(..Gc e S'`ee.C�
Thomas I-}tdebraW6l _ ft. ft.
Facility/Owner Name Facility ID#(if applicable�)- ft.
6 V/8 4 -€ c�.s4r /I w y ft. K. �-� ; ' �4 �-` �
Physical Address,City,and Zip ft. ft �nn�}
Lin/'Op Ou-3a r lI L/ E 21REIViARGS, r; l ;0`:: It ?County I Parcel Identification No.(PIN) In�rY�:.+�. fit..� s.,. Lp
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: pSw(3i0(n
(if well
field,one lot/
lllong is sufficient) / �r 2 Ai
22.Certification: 9,
117 7(Q L� rJ/�� N ��o (47 J 7 r! W -� it�-ail-a23
Sieg6.Is(are)the well(s): efPermanent or ❑Temporary of ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: [Wes or ersi 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 remark 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 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).!You may also attach additional pages if necessary.
drilled: /
240 .SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 22©100')
r 10.Static water level below top of casing: 3- (ft')
24a. For All Wells: Original Iform to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+" 1
11.Borehole diameter: a /� (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
/� ( Program,1636 MSC,Raleigh,NC 27699-1636
/1 12.Well construction method: f�/ `t ry 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
�~ n Permit Program,1611 MSC,Raleigh,NC"27699-1611
13a.Yield(gpm) i5 Method of test: A 1
13b.Disinfection type: hi T/7 Amount:,J„/.f r)'7 5
1