GW1--02383_Well Construction - GW1_20240423

WELL('O\STRU CTION RE('()RI)IGW•I1 I
InnMinnat6eodj (' '.:) i
I.wAl l'atntaA
. a InGnm
rtt6.tt:
Nick Young itwArnaznn i
-
well t'oltmter .t. twist to t t Xt
4605-A 10 1,L 1 s ` - III —
n. IL
'\\'�1 t:mstrattrn.t m t m•�E.,rnh..
4 t3.nt r 1 RR CA.Y1Pnl(tar mnN1 taint wr11t1 OR um,
I V.W. Poole Well and Pump Co ft11IN ill j IlllMf FIR IstriV/=ilirill im,
I. v e -- ‘( n. 3 0 tr. ) Cr I' I.(it/ I
1 A 16.INNY.R.C.ARi se.OR I IIBING(gent.v_rl cloud tamp)
l\dl Construction lion 1'tT7nit#: •J l.."C�(�7 INq�i U n Il\Mrian _ rtikri onts_-1 1Llff16LL,
... a:+:•^,r-.r,'•lr well. +nstvrnroi ln•mnfx p e i 1. w'ro,no'.ri o,-,I sr.,rmr etc I nt n. In
t.Well 1'se tehee 1.well use,: ft. n• in
Water Supply Well: IT.St'RRRY ------ _.
most tonts i tin .trot N/tti [MX`KNFs 4 j.N.ArIRlU,_—
l:neulnlral ❑\tuniegxil<Publit R. o- In '
Aatelninnl tlleating'Co ling,S1tpplv1 itpcsidential Water Supply(single) —- ti-•---- R la -
2htdustnnl Commercial ❑Residential Water Supply(shored) --
tx.t;ttUtR
1:lieahm ❑Fells�10Qt1111p F9a1 to MATERIAL —
FMPt.al'r M):•T METHOD R_\Mid tii
'ion-Water Sltriply Well: 0 ft. 3 0n- 11 1�\lC, e 10 r— _
\Itmilorinl• °Roe en' rt. n. n?
injection Well: _ __---_- .__
n. R
CAgmf r Re-charge OGroundvo to Remohahon --
-A uitiT Storage and Raovey 19.SAND/GRAVEL VEL PACK(if appllmbtei —--
Q t- ❑Salinity Barrier FROM TO MAIER/.AI. EMN-Ari:NE',I MI.MOD
�..iquit.T Test OStemmata Drainage a r<
DExpeimtnlal Tahnology OSubsidence Control It. It.
Ctibthv-mat(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional throes If necrssrn)
L_'C'thcnnnl i Heating Cooling Return) ❑Outer(cyalain under 421 Remarks) FROM Tot DFSCRIPT[OVS br,narm»R mil/rock t.p.,fray Act aQi
O 11. `r t` -f ne cos 1
1.Date\\eli(s)Completed:eZ-1011e'o2 4 "tell 11)h a n• t CI n• Stifle)
t , +^ .
tG ti Its 2 G, ,yk/A1 .. s,�..
Via.\\'ell Location: Qr C '�,,..i V 5.-L.
in 1,—c/ (Oa 4"S R R
...alr� ztcr\a.•re Facility DO(if applicable)
n. ft APR 2 ' /G C4
-)o+ae. CIRA direr,s Noe,,,.S f jhtda Iesev ne Y1 !1 ,:r�4y;•w
Pttrsmal:Address.City,and Z:p R R . . .. �.
JO C S(� 21.REMARKS
Cis 3
Couo4' t Parccl Identification No.(PIN) Used steel hardened drive shoe
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i}we!I field,one lsvlong is sufficient) -22.Certification:
��La`rim a�ir� �"'�!� - 1a-a�
6.Is(are)the well(s): L'�Perrtanent or ❑Temporary Sngnat c of ell Comm,r Date
Sy signing this form,I herby ce ,N that the walls/was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or CNo ill NCIC 02('.0100 or 15,1 NCAC 02C.0100 W.lt Consrrucnon standards and that a corn
if des is a repair.Jill out knows well construction information and explain Ow nature of the of this record lugs been provided to the well owner
repair ender a21 remarks setion or on the back of this form
23.Site diagram or additional well details:
g For Geoprobey'DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional'sell ctatstructinn info
construction,only t GW-I is needed. Indicate TOTAL NUMBER of wells (add Odin Rwuarks Box).You may also attach additional panes if necessary.
drillui: 21.SURNHTTAI.INSTRUCTIONS
(9.Total well depth below land surface: aS (fL)
For multiple wells list all depths jthfferent(erampk-3@200'and 2,r1g100') Submit this G W-1 within 30 days of well completion per the follow Mg:
1 0 24a. For MI Wells: Original form to Division of Water Resources (1)WR)
10.Static water level below top of easing: (TL) Information Processing Unit,1617 MSC,Raleigh.NC 276)')-1617
:l cater level a above casing.use'•,-"
tt Copy DWR,Undo ground Injatian Control(II'12
11.Borehole diameter: 6 (I,) Program.For 1636 ion Wells:h, to
1636 MSC,Raleigh,NC 2767)-1636
Rotary
12.Well construction method: 24c.For Water Supply and Open-Loup Ceitthernal Return Wells;espy IsI
':c asgr.rotary.cable.direct push,tic) county aivIronmental hiedth department of tar_county'Slier:m:IalLat
FOR WATER SLPPLY WELLS ONLY:13a.Yield(gpm) ` / 21d For Water Wells producing user 111,1100 GPlY.Cops to UW6L Q1[3°..
(/Q Method of test:Blow Pent Program.1611\k,Raleigh-NC 2to'A-tel I
1311 1)isd'e irction HTH type: Amount:
North Carolina Department of Environmental Qeuhty-IJrcaa.m at.U's:er h_. ..._. teewaurd 6-la