GW1--01706_Well Construction - GW1_20240315

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WED,;COti TRU T1I0N RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
C' Y ?O 4--p y
i1)r 19.WATER ZONES 1 11
FROM TO DESCRIPTION
Well Contractor Name A '.B. ( 12.q,: '� b rt. k` �'Iv U I cL`�
11 � ft. ft. �► I 11
Vd
NC Weli ntractor Certification Number 15.OUTER CASING(far multi-cased wells)OR LINER(if ap licable)
YF.i7Kl",!WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Comeau-,Name' Y r� 16.INNER CASING OR TUBING(geotherrnal dosed-loop)
2.Well Construction Permit#: toe , 2 3- V 2.( 0 FROM TO DIAMETER TRiCIINFSS MATERIAL�{�,
List all oppllcable well construction permits(le.UIC,County,State,Variance,etc) 6. ft. 1) ff �65, l1°' �� 310��1 VI`E '
s
3..!- lI Use(check well use): ft ft. in
17.SCREEN I
• Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Stipply) ❑Residential Water Supply(single) rt. ft. iq•
DIndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOU T
Don Watn ii o
NonYt:aterSupply Weil: 0 ft. ��ft. 1},�r � )1.,tn/���
❑Mon:`oring DRecovery it. ft. li �'W°
Injecti"D Well: ft, ft.
❑Aqu•er Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAqu:er Storage and Recovery3 ❑Salinityl3anier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aqu er Test bStormwater Drainage ft. ft.
Dap!:imental Technology ❑Subsidence Control ft. ft.
ieo .ermal(Closed Loop) - ❑Tracer 1 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
DGeo'aernial(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) 6 ft. �6 ft scy-•I
0 �[�
4.Dat. Well(s)Completed: it•��1.v Well # '{ �© ft. Mkt.' Q Rkt
i Tor,t-,6ts h. , ft. ft. v
5a W al Location: Phone # q f q_10 k-Zf33' '
ft.' - ft
De. r,S.-.UU6'tige,. ' t-= 'ice:;— yt-
)
Fa..:'t :Ownct Name Facility ID#(if applicable) ft, ft.
p gWvp t� y �l
�� _ J r I
ft., ft. MAR 1 ` CQZ�} •
Physic/1 Address,City,and Zip JC.Y ai 5,� ft. ft
}r4iurirr es re t `... Fjg:4;).am- Link
21.REMARKS nt IC.;
Count: '� '�:i('II1 ParcelldentiftcationNo.(PIN) BORES (3)(EPTH} (33(�! . - (..._ ) ,.6.-p)G .2 7,c
5b.L.titude and longitude in degrees/minutes/seconds or decimal degrees: Y,OOPS PER BORE ( ) DIA OF LOOPS( )
(if wcl,5eld,onelatllongissufficient) 22.C rtifleation: . SDR OF LOOPS ( )
6.Is(: -e)the well(s): kPermanent or, ❑Temporary Signature of Certified Well Contractor Date
. By signing this form,I hereby cert fy that1 the well(s)was(were)constructed in accordance with
7.Is' is a repair to an existing well: ❑Yes or Ao 15A NCAC 02C.0100 or ISA NC/IC 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'121 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
8.Fa. Geo robe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
const ration,o 1 GW 1 is eded. Indicate TOTAL NUMBER of wells , (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drille C-' I; 2 c,1 24.SUBMITTALINSTRUCl_JN5
'o ii well depth below land surface: ' '. '1. 0. 1(ft.) Submit this GW-1 within 30 days of well completion per the following:
Fa- HI*welts list all depths if different(example-3Q200'and 2Q1001
2 ,24a. For All Wells: Original formto Division of Water Resources (DWR),
10,.5t_e ister level below top of casing: J (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaie-ioyarl l is above casing,use"+„
Bit Off: .SO• Tl ^ 24b.For Injection Wells: Copy'to DWR,Underground Injection Control(IUC)
11.1i:rehole diameter: (in•) Program,1636 MSC,Raleigh,NC 27699-1636.
AIR ROTARY
12.V 1 construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.ai er,rc;. able,direct push,etc') county environmental health department of the county where installed
• FOR'VATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.• held(gpm) 1 Method of test: �T/�h j Permit Program,1611 MSC,Raleigh,NC 27699-1611
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•�' 6,D - 1 OZ DATE SITE VISITED: IIi 3b. isinfection type: ® Amount:
Price_ VISITED BY:
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