GW1--00953_Well Construction - GW1_20240208

••SJSJ I V v1'1.J 11\V V 11V'1 J.WS..VSt4Z. %V•♦-1I I.Va 1111..111,11 aJOG vaaay.
•
1.Well Contractor Information:r / J �j/� •
,�eFFce� / e c i.Y 1 /I e/l///'7 23ei 'f 14.3WATER•ZONES
Well Contractor FROM TO DESCRIPTION
.] ft., 1T.
I
( 6 O 2 It. it.
� I
•
NCC Well Contractor Ce-rtiificationNumber / Q ) .15::OUTERCASING(foimulti-caskd'wells)ORLINER(ifap"Usable)
//J L r ///t /f rS wCJL/ f r ze,-/7 Gy 4Ic ;7'
' TOO 6 DIAMETER THICKNESSs MATERIAL
Company Name �✓ / fG V (JfG S � /t/pZ J �v C
7 tl r� / 16.INNER.CASING:ORTUBING:(peothermalclosed4aopj
2.Well Construction-Permit#: J a /2 U(O 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: 17 SCREEN`'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. !t. In.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. g, 'in. -
❑industrial/Commercial ❑Residential Water Supply(shared)
;:18.GROUT::,.;"• ,.,. :: .. ,,.
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT Ammo&AMOUNT
Non-Water Supply Well: a ft. a 0 ft. 0 P®
OMonitoring ❑Recovery ft. f.
Injection Well:
ft. ft.
❑Aquifer Recharge - ❑Groundwater Remediation
.19 SAND/GRAVEG.PACK(if applicable): ._
❑Aquifer Storage and Recovery • ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. 1
❑Experimental Technology ❑Subsidence Control ft. ft. I
OGeothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG(uttaclrudditional sheets:ffnecessary) . .
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness soWroektype grain size eta)
�"j o fG o(0 ft. R'cJ CCU/
4.Date Well(s)Completed:1 ' '/ � Well ID# 0 ft" .'S 6, ft.
An©„ /f
5a.Well Location: :,t 37 t ft. j c,ft. �d 2 Q Chi
Pio -er Re- -
Facility/Owner Name Facility lD#(if applicable) ft. R. 7 , ,A
/'6730 wh;-/e .sl iate d. V CU
P ical Address,City,and Zip [�(� (� /� ft. FEB 0.8 7n2A
' '1,1 1r� 1 W v W I�� 37 REMARKS>:
lnfoff i'fijen,P.
County Parcel Identification No.(PIN) .tl 1fl
rivitOOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
l a F5 17 old
�' N YIP, 3 o 051 W ,7' � \ •2
6Is(are)the well(s): 1131 r nanent or ❑Temporary itrofC ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed In accordance.wlth
7._Is this a repair to an existing well: ❑Yes or l»o 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
!filar 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 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 I GW-it 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: 5-.0 (ft") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2©100)
® (ft:) 24a. For All Wells: Original j form to Division of Water Resources (DWR),
10.Static water level below top of casing:
If water level is above casing,use"+/`If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: %$ (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �D,LaZ/"� 24c.For Water Supply and Oplen-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
13a.Yield(gpm) �/ u Method.of test: •t� t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: !T 7 ' /' Amount:, 3 p i# 1-5
i