GW1--01830_Well Construction - GW1_20240322

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I
WELL CONSTRUCTION RECORD(GW-1)
For Internal Use Only
I.Well Contractor Information:
//t ern6v,.,6€,-/� I
14•WATER ZONES
Well Contractor Name
FROM TO I DESCRIPTION
NC Well Contractor Certification Number ft ft. I
��a / 15.OUTER CASING(for niulti-cased wells)OR LINER(If ap Ilcahle)
I3 e/f. - / k --,,, L ti 4-4.,[ FROM ICASING
MAMMALTO ;DIAMETER THICKNESS MAALCompany Nameft. ft. II . in.2.Well Consd uction Permit N: �'! p J U b �a 16.INNER OR TUBING(geothermal closed-loop)
FR
List all applicable nellconshvrctlon permits(i.e.U/C County,State,Variance,etc.) `OyM ft TO/ DIAMETER THICKNESS MAQTERIAL
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TKO/l DIAMETER SLOT SIZE THICKNESS MATERIAL
❑AgflCn)ttna! ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f t 7 fj ft, > in. f© S,C 1-10 �C
❑htdustriaUComnlercial ft• ft, , • in.
❑Residential Water Supply(shared)
❑litigation 18.GROUT
❑Wells> 100,000 GPD FROMdi
TO _
Non-Water Supply Well: G, atATER1Al.' EMPLACEMENT METHOD A AMOUNT'
lonitorin - ft. Z fL 8x,,,i st fe Ele.t /=/o w
g ❑Recovery s/��/
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery OSalinity Barrier 19,SAND/GRAVEL PACK(if applicable)
❑Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
❑Stonmvater Drainage • . . .3 y ft. 4/6 ft. ,x#/ e?� .-rti s'/0(4, isov r-
❑Experimental Technology ❑Subsidence Control T"fir 0. 'a`�� d'Tn f
tt. ft.
❑Geothermal(Closed Loop) ❑Tmcer
20.DRILLING LOG(attach additional sheets if necessary)❑Geothermal(Heating/Cooling Return) ❑Other•(explain under021 Remarks) FROM TO DESCRIPTION(color,hardness,salUrock -"'type,grain size,etc.)
4.Date Well(s)Completed: "��-� Li r� ft. Zo ft. f�..A,A oo"'r'`ft~�epsa.,.-.4. /.Y(t-a
[ WelllDk R416 ®! Z0 ft• il6 it•
.443rs0,x� rl yCb, to 14`Sn.Well Location: ft. II
5••0; 12/ 7'1/S {^O G�`Fj -f lr.Cn f3 �TaPro(i/ r
ft• ft.
Tacility/Owner Name Facility IDN(if applicable) ft. ft. a• �'` ' --I
S / J -16," ,., le/ItrC 2�?I d ft. p
PhysicalAAdddress.City,andZip 2&/60 ft. f ft. I MAR 2 2 �OL4
pL'TAer-ro rd- !eV 5-2 S 21.REMARKSiry --
County
y iaoi
Parcel Identification No.(PIN) le A-,fa Go ell a &.at/I yt.i s ?.-re-r,,,^j 4,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: s.e e &Jai Abe,t.hte. ' —/ fIL(if well field,one lat/long is sufficient)
22.Certification:
3S_359Li6 N -21. 1Zyy9 W a Lf
6.Is(are)the well(s): OPermanent or i�// p ry le,
�� ��� - f.�I em orate/ gnnturc o Certified Well Contractor Date
gning
is form,I
dance with
7.Is this a repair to an existing well: ❑Yes or L'f17Vo ISAtNCAC 102C.01001or ISAereby zNCAC 02C.0200 It'!!oif*that the we/k.r) rCornstractio„s(were) sSta,nla rdst acted in tandtI/eu a cry,-
(.this is a r epah;fill out known well construction information and explain,the Mare of of this record has been provided to the well ouv,er.
repair under 021 remarks section or on the back of this faint.
23.Site diagram or additional well details:
R.For Geoprobe/DPI'or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well conShtictiori info
construction,only 1 G-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if neo:ssaty.
drilled:
1/6 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdiffer-ent(example-3Q200'and 20100) Submit this GW 1 within 30'�'days of well completion per the following:
10.Static water level below top of casing: '3 7 (ft) "24a. For All Wells: Originril form to Division of Water Resources (DWP,),
ljlvnter level is above casing,use + Information Processing Unit,1'61'7 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: '16- (ill,) 24b.For Infection Wells: C Ipy to DWR, Underground Injection Control(lUC)
2Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i f eG f Ai,
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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) Method of test Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: - Amount: -
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