GW1--07868_Well Construction - GW1_20231205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I '
1.Well Contractor Information: 1
ChU mot\% Goev 1 r C.C O El 14`WATER ZUNES 1.;-
Well ContractorNamti FROM TO DESCRIPTION
NC Well Contractor Certification Number t •
, '15::OUTER CASING'(formulti-cased wells)OR7INER(ifap"llcable)
�g� `( u 3 (g FROM TO DLAM THICKNESS MATERIAL,.
,—, i�V\V 1\ 1 YV�`1 "r U(/l� t ft. i 0 5 ft //�J 1. in. C i.r - Pv�
Company Name ' Cs 1
!\ ':16:•INNER.CASING:ORITUBING:(geotheriunlclosed4ciop) '
2.Well Construction 2 Permit#: -� Z V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction penults(Le.UIC,County,State,Variance,etc.) ft. ft. M.
3.Well Use(check well use): ft •ft in
Water Supply Well:
4 FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. 'in.
❑Geothermal(Heating/Cooling Supply) 1DResidential Water Supply(single) ft ft in. •
❑lndustrial/Commercial. ❑Residential Water Supply(shared) 18:`GROUT ..;, —a
❑Irrigation ❑Wellls>100,000 GPD . FROM TO MATERIAL • EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: 0ft. 7 b It. Deiwi/e t+x . i
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. 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.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer •i:20:DRILLING'LOG(dttneh 5ddititidal sbeetsifneecssary) .
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(c tor,hardness aaturocktypa RraIn size etc.)
❑
O ft. 20 ft. I):-mn Ic.. < ..k. '
4;Date Well(s)Completed: i i (2.2.I V'S Well ID# 2 O fttO ft R_J 5 ,
5a.Well Location: ,:it •. lab ft. 3 66 ft blue S 14 e -
fL ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. r\ t,''if j
' bO l P r-/cc,,00c S'd'1 o 112c1 ft ft. DEC 0 S 2023
Physical
Address,City,and Zip ft. ft.
' U IN l 4 o q-30&t a 21 REMARKS:', ILlivf,T ,f�Fl y i
County • Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
z t f.&4 11I22- f 5
6.Is(are)the well(s): 11j1'ermanent or ❑Temporary Signature of Certified 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: ❑Yes or iftNo 15A NCAC 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 and explain the nature of the ' of this record has been provided to d e well owner.
, repair under#21 remarks 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),IYou may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: B OO ( ) Submit this OW-1 within 30 da s of well completionper the following:
For multiple wells list all depths if different(example-3@200'and 2®100) y p
( ) 24a. For All Wells: Original'form to Division of Water Resources (DWR),
10.Static water level below top of casing: il b• ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
, If water level is above casing,use"/+'' l
11.Borehole diameter: iJ (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
a Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rc C.E>( 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 ppWELLS ONLY: /� 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
��
13a.Yield(gpm) 1 l! Method of test: it i ii Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: PIe 1 Amount: 1 ev-k