GW1--02542_Well Construction - GW1_20240426

WELL CONSTRUCTION 1ECORD (GW-1) For Internal Use Only: •
I.Well C ntractor nfo a n(: 1( ( r
(� Y ' \\ W`��•l 14.`WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
l�Q ft. g/ ft.
ao39 . •
�„r6 ft. ft.
NC Well Contractor Certification Number
^\,1\ (U�\ I Ii i\ Y I 11 1 l 4 �V vl FR�Ohf ft. TO ft. DIAM RIAL
i�R in. THICKNESS
�E� `J TV l_„�Company Name J �`
:.16:INNER.CASIN :OR TUBING.(geothermal closed loop)"
2.Well Construction Permit#: a 3^ 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft. in.
3.Welt Use(check well use): ft. ft. in.
Water Supply Well: 17scREEN- ,.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) iesidential Water Supply(single) ft. ft in. -
❑lndustriaUCommercial OResidential Water Supply(shared) _18.GROU1
❑Irrigation ❑Wells>100,000 GPD . FROM . TO MATERiIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft a© ft
h. belf-1-C PnL.Ur't•sot
❑Monitoring ❑Recovery ft. ft.
Injection Well: •
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PACK(ifapplicable) - -,.
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. ,
❑Geothermal(Closed Loop) OTracer :20:DRILLING LOG.(attach additional sheetsifnecessary)°:.- ' :•,-:- ::•..-. .
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness,soilirock type grain size.etc.)
© rt. k,0 ft.
4.Date Well(s)Completed -aLA Well ID# 1 O rt. i 1 ft. tf2 �� 5�
Sa. ell Location: A. tt. 1 / _ t (1, �LQ,��.rLA��. \'' '..
des L[Co ft- a lu ' dT i 0 > t��-�
Facility/Owner Name (� Facility 1D#(if applicable) ft. ft. J J
5y I ( _lr! 1RG. M sh(1i'� ft. ft
Ph i 1 Address,City,and Zip � ft. ft. '4 •.1r ... k...i if I....to.,:
2I:-REMARKS:...::.:' o:'n
County , Parcel Identification No.(PIN)
t InfC.: -:.%.:- ):-."r.-;' './i':!:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �•;•11.,,;w .
(if well field,one lat/long is sufficient) 22.Cer• co on:
. /310 , N g0 . 36803 w `
6.Is(are)the well(s):termanent or ❑Temporary Signature of eni6ed Well Contractor Date
By signing th form,I hereby certifythat the well(s)was(were)constructed in accordance with7.Is this a repair to an existing well: DYes or INo 1 SA NCAC 2C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information nd`explain the nature of the of this record has been provided to the well owner
repair under#21 remarks section or on the back of this form.
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 G 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: Qt�Ul_/ (t) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdferen (example-3(0200'and 2@100)
I 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: L (ft) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
Iftvater level is above casing.use•'+" I(
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
i i.Borehole diameter: 9 l 1 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well '-••-+ ction method: �.1 Y •1 t r y 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(i.e.auge rotary, :ble,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
` l Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /V Method of test: r
13b.Disinfection type:_0- Amount: \ph' j