GW1--02539_Well Construction - GW1_20240426

WELL,CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
tie FF>°i., -1(cAer /i '&';n �J a ClfjO!'l 14::WATER ZONES 1; _ ..
Well ContractorNadte FROM TO DESCRIPTION
�bft. 13`k7 3 55
a rt.
NC Well Contractor Certification Number 15..OUTERCASING'(for multi-cased wells)OR LINER('Rap lkable)•
h/ / Inca;
s ,we// g/)�/,�//n 1�C FROM TOOe DIAMETER THICKNESS MATERIAL
eV, ny /i [/ [ / ft.
�f ! f� �le in. I /2S / 1/G .
Company Name
�1�,/ C' ::16:INNER:CASING:OR TUBING';(geother'inal closed loop)
2.Well Construction Permit#: • QC + /`J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consttucdion permits(l.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.sCREEN ;:,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) It 1 sidential Water Supply(single) ft. , ft. in.
❑Industrial/Commercial 0 Residential Water Supply(shared)❑Irrigation ❑Wells>100,000GPD • FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: • ft ft
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
':19..SAND/GRAVEL PACK-(if-applicable) :..' :> ,::.::-:._,.::; :•:. ,:.
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer ;20:DRILLING LOG(atfaclradditional sheet if itetessary);,_:: . .•
-. ..
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solllrock type,grain size,etc.)
4.Date Well(s)Completed: > 1"(0;"'Well ID# PS ft 114/ ft Vezc-e s/_ f
5a, ell Location: . ° LW ft. 3 6oft. ikzee st
t �at-Q. rt. ft.
u
Facilit et ner Name FacilityID# if a licable—`' ft. ft 1.=
v /D (a,r p€.n-�,e r Rd, ft. ft �+ (. }.._._.,:
Physical Address,City,and Zip ft. ft. H P n G o L02'f
{N� y� O/ '21:-REMARIGS':--
County Parcel Identification No.(PIN) Lt^'`is �u`'
•
5ti:'Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
33. 1(4aty N . e28l0 W -G: ___ 3,0—
6.Is(are)the well(s): F�Permanent or ❑Temporary S at f Certi Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes hP- LINo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is 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 under#21 rentarla section or on the back of this forrn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 6 0 (t) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'200'and 2©100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
e 10.Static water level below top of casing: 3 S (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"•t-"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: &28' (in.) Program,1636 MSC,Raleigh,NC 27699-1636 n
12.Well construction method: R O( a ry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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
/'� i' Permit Program,1611 MSC,Raleigh,NC 27699-1611
V 13a.Yield(gpm) fa Method of test: I r
13b.Disinfection type: H T 1--i Amount 3 001 n f 7