GW1--01009_Well Construction - GW1_20240208

.V JL zIJ.J,/.vh.,Iu s l.v 4,1 lvi' 11LL'Lvitfj tUr rY-d1 ror Internal use only:
1.Well Contractor Information: •
jeffreV O1 e c' /l/ or/a.7 /'/'i C e .14r'WATER ZONES- 1 , .
Well Contractor N FROM TO DESCRIPTION
A1 d2o ft. ft. 7 j ��� 3 So
ft. ft.
NC Well Contractor Certification Number
15.:OUTERCASINGfor Multi-Cased_wells)OR LINER(ifap liable)''/.
:'..-.-:
FROM TO DIAMETER THICKNESS MATERIAL/e /234/6-5wet/ `Ve,'L(!n I l�/vCI' ' f &5'it ✓/5/in. d/2s Pc..Company Name
16•INNER,CASING:ORTUBING(geothermal closed loop)
2.Well Coaslruction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count. tate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ".I7.SCREEN. .-. r: -„< :.:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ��OMunicipal/Public ft. ft. ; in.
OGeothermal(Heating/Cooling Supply) Wesidential Water Supply(single) (I• ft. is -
❑Industrial/Commercial ❑Residential Water Supply(shared) ':;`18.GRO1T1' , .
❑irrigation OWells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R. 61 0 a. G'�' �at< - too u r e ci
OMonitoring ❑Recovery ft. ft t`��
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 n• ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer ;20/DRILLING LOG,(attachadditionalstteets:ifnecessary) -. .
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soil/rocktype RroIn size etc.)
v ft (2oft. ' led IfLY
4.Date Well(s)Completed: /a'-/•'c23 Well ID# /) ft Sc ft _S�-id 574"V.
5 . ellLocation; :-i `j 0 ft• C-V ' . 6.-,-1,1.sfo/ie/&Lccto .5L
Facility/Owner Name Facility ID# "applicable) ft. ft I"- -+w �, wu Y-
36 /i�ver bL/.�1- LA' ft. ft. "�► � 1 ...?
P ical Address,City,and Zip ft. ft. F EH
,
. . 7L3) 1174 Z112E143ARICSr 0.27
linty Parcel Identification No.(PIN) Iffillf2LT.d'sf!°fl,Procaosi•6t'-Ufi
DWQI OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35s01641 N /7 94 8 '9504/ W
/ 'a3
6.Is(are)the well(s): liaFrm eanent or ❑Temporary f Ce ' Well Contractor t ^
By signing this form,I hereby certifv,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or gig( ISA NCAC 02C.0100 or ISA 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 the well owner.
, repair under#21 remarks section or on the back of t is 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 G 1-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11:9 0 (ft,)
For multiple wells list all depths(fd�erent(example-3@200'and 2(100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3..9 (fL) 24a. Far All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,If water level is above casing.use"+"
NC 27699-1617
11.Borehole diameter: /� (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
L Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: %1 D/ ary 24e.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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
la n r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) , Method of test: /7/ I"
13b.Disinfection type: L7f 1'/1 Amount.3,p '7L5