GW1--01703_Well Construction - GW1_20240315

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QVE,LI C2or/3TR1UCT11'0l! RECORD(GIN-1) For Internal Use Only: . •
1.Well Contractor Information:
6dyPo Redd )c1Sld Aus�i� 14.WATER ZONES FROM • TO DESCRIPTION
Well CororactorName /r te
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedlriells)OR LINER(it ap licable)
YP.DKI 1 WELL COMPANY,INC. FROM To DIAMETER 1 THICKNESS 1 MATERIAL
ft. ft. 11in.
Compan• Name. 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: PU 2 3-- 0 2 6 (0 FROM TO DIAMI IFR THICKNESS MATERIAL
List all r,.-pllcable well construction permits(i.e.UIC,County,State,Variance,etc) 6 IL 1s4 ft- 'la s/f$I m t 1 CL S 131aG� L•{�p�a,
k. k. 1 in. - 1(J c�l� r
3. Ai Use(check well use): I
17.SCREEN
WeLsr Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/PubIic rt. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
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❑lndui rial/Conunercial ❑Residential Water Supply(shared) 18.GROUT I •
(Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL
p/ EMPLACCIE•ENT METHOD&AMOUNT
Non-Water.Supply Well: O ft. 34 ft. ��/N f' 19 Jc 'L
❑Mon:toring' OReeovery . P, ft. ft. ' .
Injecti n Well: ft. ft.
❑Aqu e•'er Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aqu•,•br Storage and Recovery OSalinity Bonier FROM TO MATERIAL • E11EPLACEMENTMETHOD
❑Aqu••er Test o5termwater Drainage ft. ft.
❑Expr:imental Technology OSubsidence Control ft• ft•
1
6 reo:.ermal(Closed Loop) ❑Traces 20.DRILLING LOG(attach additional sheets if necessary)
FROM • TOo DES DESCRIPTION(color,hardness,toiUrocktype,grain size,etc.)
❑Gear iermal(Heating/CoolingRetum) ❑Other.(explain under#21 Remarks) ft �O ft C�i yl
4.Dal Well(s)Completed: .' % #akk Well Oft �GX��� �g0 ft. 3l ft. � �
�)V' 3101^w'itmf'a : ft. ft.
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5a w:ll Location: Phone # C i q-40 g-2i: 3 . ' • r-:. !r-'. . •.
, fL' ft. :.I •E t-.. ...,e L. i i I--?n..
6y
Fa..:'':,•OwnerName FacilityID1l(ifapplicable) ft. ft. MAR 1 5 20Z4
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-5 Q y 6oc'1(A.A.)-�� tiles Ch.a� � L4J'f ( • ft. ft. ���a
-J N�{L' ' ft. ft. ' ' 1 IrliC.WC 4Q:'1 :=...,, •.•...o
Plrysie.i Address,City,and Zip 1��i�'��jl ' 1 riwCt•'3OG
,r� 21.REMARKS
Count; �- Parcel Identification No.(PIN) BORES (3)Q.DEPTH !(3 )•' r C �S &s,G"P)e 271,
5b:L.•fitnde•atid longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( ) DIA OF LOOPS( )
(ifwel,field,one lat/longis sufficient) '7 ++ 22.Certification: SDR OF LOOPS ( )
44 ,�� 1
6.Is(, •e)the well(s): �Permaoent or, OTemporary Signature of ed Well Contractor Date
By signing this form,I hereby cert fy that the wells)was(were)constructed in accordance with
7.Is. is a repair to an existing well: OYes or (lfIo 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this ;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 nder 1121 remarks section or on the back of this form. , ,
23.Site diagram or additional well details: •
8.Fo. Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pages to provide additional well construction info
coast,Iction,on}y I G0.is r�Geded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarla Box).You may also attach additional pages if necessary.
drille (� Cep 24.SUBMflTAL INSTRUC1..JNS
'o 11 wed depth below land surface: .�� (ft.) Submit this GW-1 within 30 days iof well completion per the following:
Fo• *le wells list all depths if different(example-3@200'and2©100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.St::tic water level below top of casing: (ft') 'Information Processing Unit,1617 SC,Raleigh,NC 27699-1617
Ifwate-level is above casing,use"+"
11.B:rehole diameter: U in.) Bit Off: S.gi Li 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636.
AIR ROTARY
12,V_'ll construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e•al cr,.at r-•,;'..tile,direct push,etc.) county environmental health departiiient of the county where installed
• FOR VATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing I'ver 100,000 GPD: Copy to DWR,CCPCUA
A
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a. field(gpm) Sa Method of test: /"! It' f
13b. .isinfection type: (U kka 'rtG Amount: 1 OZ • ,DATE SITE VISITED:
Pri,iP= �"
VISITED BY:
e_- .at 1 K T.. 1.r',.,.1:..,rl...,.r..,..,,,.rp,..d..............1 rl,,l:h,_rlh,ie.nn ne mr,,,.-A....,...:.I n---.-a<<9m e