GW1--00951_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD(GW-1' For Internal Use Only: •
1.Well Contractor Information:
lket V %r-> \.30A1� C ak/\r- j u1L.ksb/•1 -14 WATER ZONES ':: -t : _
Well Contractor Name FROM iTO DESCRIPTION
�!r ��fL,, 1�� ft. i
j
1 r�ort. I a U ft.
NC Well.Contractor Certification Number [� •
15..OUTER CASING(for multi-cased wells)•OR LINER(ifap licable)•:',
t� i ► k,1\\ ♦. I QC �1 \ \ `\\ \^ FROM ft {TOy ft. ' D/IAME ER in• THICKNESS MATERIAL -
Company Name ` w \` �J \ s \�, - 1 "i� l7 �� a 1�ES
..16:1NNER CASING:OR'TUBING-(geotherinal closed-loop):. .-. ..--`
2.Well Construction:Permit#: 22'-
-
1 1 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.
4 Water Supply Well:
-FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 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: D ft. 20 ft. f��.it1 ( p Q�Y.•
❑Monitoring ❑Recovery ft. ft i�CJ
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation
19.SAND/GRAVEL PACK(if apphcable) =... -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)<', • ._ . .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrnck type gain size.etc.)
I
I) ft. 21ft. fie- G1 Cy4.Date Wells)Completed: Zit 2 4 Well ID# +l.p ft too ft bv,t>�� ram/A.
c. Gft. y
•
5a.Well Location: 160 ft. /L(() Sat it c15 t�
1 ` `,t i j
) , �-�orv- e S it'J I ft 00 ft.
6r[.\'te F/Y1r ,-.., c
Facility/Owner Name FacilityID#(if applicable), ft ft 4''5.»" t t
e y � 1 �.f(�Leo t
B l 1 C)c, �C.,aIJ mon roe__ \�= ft ft. �'�-8 tr J 2024
Physical1 Address City,and Zip y� ft. ft.
v�1\ D w-� V5-4�G1 e -�' \ 21.'REMARICS. -, - tutor t!a if?�n Prnr..� :L(,Yk. '-.
DWCYBOG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
34•.Rt C` . N PC,``fV21-1 S W 1 I21 1"7-ki-
6.Is(are)the well(s): °Permanent or ❑Temporary attire 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 Irio 1 SA NCAC 02C.0100 or ISA NC,IC 02C.0200 Well Construction Standards and that a copy
If this is a repair fill out brtongt well construction information and explain the nature of the of this record has been provided to the well owner. --•
repair under#21 rattails 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ® (ft.) per Submit this GW-1 within 30 days of well completionthe following:
For multiple wells list all depths if different(example-3@200'and 2@100') y p
r 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: el 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.useJ"_+"
11.Borehole diameter r (in.) . 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
pp Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /s•\f" 1-��A 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 SUPPLYCWELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) .✓ Method of test: V -A Permit Program,1611 MSC,Raleigh,NC 27699-1611
`�_ 1 I
13b.Disinfection type: 1A-% k4 Amount: \ i Y1 1