GW1--00950_Well Construction - GW1_20240208

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WELL CONSTRUCTION RECORD(OW-1) For Internal Use Only:
1.Well Contractor Information:
i INCAA: MJ1\1S I J&cxvr JG.C.kSC!1'1 14:WATERZONES
Well Contractor Nam FROM TO DESCRIPTION
€t) ft ft.
"Z v3 G - v.2. ft.r" 1 Lc.
ft.
NC Well Contractor Certification Number • .15.:OiTTER CASING(for multi-cased wells OR LINER if a licable -
/L `` i FROM TO DIAMETER ) THICKNESS p MATERIAL`
�`-- IV W \� vV� '� lrS�� r�� � ‘ ft. 1.,�y ft. 6 1,l e in. 1 /Ls- 1 `(
Company Name
a 16.INNER CASING:OR TUBING( ther"mat'closed-loop):::•. •'' -
2.Well Construction:Permit#: : Z..,) - 31 4, 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): fr. -ft. in.
4 Water Supply Well 17-SCREEN : .::i
-FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic it ft. in.
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ft, ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 2 o ft. ,i` pOI.UC-t V
❑Monitoring ❑Recovery ft. ft.
Injection Well:
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ft. R.
❑Aquifer Recharge - ❑Groundwater Remediation
-19.SAND/GRAVEL PACK-Of applicable)............ . ...... _
OAgttifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ;;20.DRILLING-LOG(attach additional'sheets ifnecessary) -. ... ..:_.,-.-:'. :__.-..:r„ '.,::
OGeothermal(Heating/Cooling Return) - ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,son/rnck type train size etc.)
O ft. 1( r
ft. e_c C. 1 c
4.Date Well(s)Completed: i—/f-`,'/Well 1D# ( 0 ft 20 ft. .b wc,.�,, ej
5a.Well Location: ,t• 7 0ft. 2 4b f. \-N L.) S' 1 G ern,
` ,n A i t ft. ft. `
Facility/OwnerName Facility ID#(if applicable) ft. ft.
n f. ft.
3-i t 3 S t Ice s vv\\<` 1 _ _
Physical Address,i ity,and Zip ft. ft. K.,e ` ,, 'u - ^^
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County Parcel Identification No.(PIN) I LD 0.8 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1-ntr :__k;1? .;r,,Urv;.
(if well field,one lat/long is sufficient) 22.Certification: DwQmoG
''55.rN o N e0; q`Ze- w
6.Is(are)the well(s): 'ermanent or ❑Temporary Signature of Certified ell Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: DYes or @!No 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 it formation 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.
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: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24 (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdijjerent(example-3Q200'and 2@100')
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' 1' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3® (fW) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"T" -
11.Borehole diameter: 1 t.) (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A\t— 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: J� . 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 S Method of test:
A \tl— Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: i i + Amount: C p\i\_ •