GW1--00285_Well Construction - GW1_20240105

...-i.� -'J1 Lim u c'1'!ON RECORD GW-1
For Internal Use Only:
1.Well Contractor Information:
Well Contractor Name v ck C k'on 14.WATER TONES
FROM TO DESCRIPTION
R'
NC Well Contractor Certification Number ff. ft.
hl y�A ` ` 15.OUTER CASING for multi-cased wells OR LINER f a liable
S •
1 C�`� �r' \ IN FROitf ft. T14s rt. a it 'TER THICKINESS MATERIAL
Company Name
in. t i'Z7 I ‘iC 2.Well Construction Permit#: CA A-ul _ 16.INNER CASING OR TUBING eotbermal dosed-loo
List all applicable well constriction permits(i.e,UIC,County,Sttaat02 31Ce� i F oM,etc.) ft T6 nlwt�iert THICKNESS MATERIAL
3.Well Use(cheek well use): m.
ft. ft. In.
Water Supply Welk77.SCREEN
FROM TO DIAMETER SLOT SIZE
THICKNESS
MATERIAL
°Agricultural DMunicipal/PubliC
DGeotherinal(Heating/Cooling Supply) rbSupply( g )Residential Water (sing le R in. _
Olndustrial/Commercial e. it �_
❑Residential Water Supply(shared)
❑Irri ation °Wells>100,000 GPD 1188.oGtROUT
TO MATERIAL • EMPLACEMENTM oD&AMOrrrrr
Non-Water Supply Well:
❑Monitoring tj ft. ? ft. y
Injection Well: DRecovery t'f�C QV
ft.
DAquifer Recharge °Groundwater Remediation ft. R
°Aquifer Storage and Recovery ❑Salinity Barrier 19 SAND/GRAVELTOPACK If a 'Ruble
°Aquifer Test FROM TO ft. 111111111111111111
: EMPLACEMENT METHOD
°Stomtwater Drainageft.
°Experimental Technology °Subsidence Control
❑Geothermal(Closed Loop) ft ft.°Tracer 20.DRILLING LOG attach additional sheets if accuse
❑Geothermal(Heating/Cooling Return) OOther(ex lain under#21 Remarks) FROM TO
DESCRIPTION enter,herdeau,soh/roeh size.ate.)
/-� o !t. � t7 R,
4 Date Well(s)Completed: 1 Well ID# ` 6'"'e7c.�.n �, a-
5a.WeltLocation: �;. / v tt 20 n 5C4P18S t'1
�� + ze �?(00 • h l,a S �a
G�t� �1�� .; fL ft.
Facility/O nerNama Facility lD#(ifa liable) ft. R.
bS S,„► L ft.Physical Address.City,and Zip rt. �-. �
(�'�� fL ft �..."
�- 1�eV� 27.REMAIC3
County
4 N 0 << 2024
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tn'Cr�' :i� 1?r.��
(if well field,one let/long is sufficient) 3 9 tlk3
22.Certificatio : DOt 4,y3°G
a5 , 33'44 5 N_��r I C2r1 W 9
6.Is(are)the well(s):.SPermanent or °Temporary Signature of Certified Well Contractorr //_ w z�
Date
7.Is this a repair to an existing well: °Yes or +plVo By signing this form,1 hereby certij'that the well(s)wog(were)constructed In accordance with
If this is a repair,fill out know,,well construction Information and explain the nature of the fd NCAC d haC s
providedor SA NCAthowe.0200 Well Construction Standards and that a copy
, repair under#21 remarks section or on the back of this form.
of record has been to the well owner.
• 23.Site diagram or additional well details:
B.For GeoprobetDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
r'�r t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( I
For nw/nple wells list all depths([different(example-3Q100'and 1Q/00) (n) Submit this GW-1 within 30 days of well completion per the following:
�' (.) 24a. For All Wells: Original form to Division of Water Resources
' If water level it above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 (DWR),
10.Static water level below top of casing:
11.Borehole diameter: j/B `(In.)
Program,1636 MSC,Raleigh,NC 27699-1636 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1[IC)
12.Well construction method:__ 1r A '- t—�
,eta) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
N 24d.For Water Wells roducin over 100 000 GPD:Copyto 13a.Yield(gpm) Method of test: • Permit Program,1611 MSC,Raleigh, C 27699-1611 D CCPCUA
13b.Disinfection type: f+-7 4 Amount: 1 p