GW1--01829_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1)
For Internal Use Only:
1.Well Contractor Information:
//Oi//1'G`An W/ J'►V3-erlY
14.WATER ZONES I ' _
Well Contractor Name FROM TO DESCRIPTION
. e7 / 33sit. son' '.� ,y
c,r�/Zt�/41�va�Qr
NC I Contractor Certification Number00 It• ft.
I
/-/15 v/ rd me,1.� 15.OUTER CASING(for multi-cased wells)OR LiNER(if ap Ilcable) -
FROM I TO I I DIAMETER f THICKNESS
MATERIAL
Company Name ft• ft. In.
�n
2.Well Construction Permit/{: tit)r' 1 D`(1 b �� 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO 1 DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U!C.Cmaey,State,Variance,etc.) 0 ft. 1/0 R,
In. .��4 yU / v� .
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
❑AIpiCUlhtral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public t�/d ft. -a ft. / in. 49/Q .514.9 U
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) pp,.
ft• ft. in.❑Industrial/Commercial
❑Residential Water Supply(shared)
Obligation18.GROUT ,. -
❑Wells> 100,000 GPD FROM TO ' MATERIAL.' EMPLACEMENT METHOD&AMOUVI
Non-Water Supply Well: it. 3 ft.. j
(onitoting i;p . fe Grc,,,,;sty /=/v7�
❑Recovery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation It. ft.
OAquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) •
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonmvater Drainage •• .. 3 e ft. ft. 'abl (Q� �tz
❑Experimental Technology . . �D �,/ _��, ��S'/ow J"vr,�cj- L�
❑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 DFSCRIPTtON(color,hardness,sel0rork type,grain size,ma
C�e4.4
4.Date Well(s)Completed: Well ID#2_� + G` / C/6-i.e.y�u'>c c-7a/tvd LY-GJ
R 0 C ,1 2_.i ft. Sj! IL 6/'60,,t 1�6,...a41 S�.tk.y ir
5n.Well Location: r 1 ft. n, �J j
Lo ever-ear,;5 retLic ✓a es,es,
sP 6140�/17,//s ft. , , �- S
Facility/Owner Name r •- • ' +f
Facility UM(if applicable) ft. ft. E •a 1m, +°5-..i; v @. L-I
/L1/ S ;/v' esl-�e rt.A.hley/VC 22/10 ft. ft. ' , MAR 2 2 202.4 Physical Address,Cit ,and Zip ft. ft. --�
40 Iasi-Vb e. 6- 9 _ t,
•y (� 21.REMARKS
Count 2 �d ���� � lllfiii e'Ciir:�-, � ......"^"':•,;,
Y /�� / t i' Jr
Parcel identification No.(PIN) /v rk n UL e,4! ii ouv ri° � Sim �� t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . r e �eGl Gk.gcL'r.G�d��[-•4��9COr--71-1 J
(if well field,one tat/long is sufficient)
22.Certification:
5. 3S% Li 6 N '• gl. 72._q it
6.is(are)the well(s): ❑Permanent or L>R7'emporary tgnaturc of Certified Well Contractor ,� Date
By signing this form,1 hereby cc,lil•that the well(r)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or itt 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Wel(Cotrstrrtction Stnadmdr and that a cola
If this iv a repair,fill out known ivell constntct(on information and explain the nature of the of this record has heen provided to the well oawer%
repair under 01l remarks section or on the back of this torn.
23.Site diagram or additional well details:
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well consfntction info
construction,only 1 GW-I 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: O (ft.)
For multiple wells list all depths ifdi(ferent(example-3@200'200'and 2@100) Submit this G�V 1 within 30'days of well completion per the following:
10.Static water level below top of casing:
33.-5- •24a. For All Wells: Ori4inal form to Division of Water Resources (DWR),
If water level is above casing,use"+^ (ft.) information Processing Unit, 661'7 MSC,Raleigh,NC 27699-I617
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 2 :2-5 (Ill.)
// Program,1636 MSC,Raleigh,INC 27699-1636
12.Well construction method: P iI'' Ge w-5 h
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health di partment of the county where installed
FOR WATER SUPPLY WELLS ONLY: •
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
I3a.Yield(gpm) Permit Program, 1611 MSC,Raleigh,NC 27699-1611
Method of test:
13b.Disinfection type: Amount: -
i
Form my-1 .� -..-....-. _. .. I