GW1--02557_Well Construction - GW1_20240426

WELL
D+ L CONST`'UCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: �j
��/el rl 4&/4- / /✓f/os-'^ Price, 14.:WATER ZONES
Well Contractor Name e `FROM TO DESCRIPTION
,
3a • / �%ft., / ft.
zOS ft. ft. •
NC Well Contractor Certification Number 15..OUTER CASING for multi-cased wells`OR LINER(if a licable
.DZ ilia iit ,„11 a ll�N ( ).
FROM TO DIAMETER TtitCKNESS MATERIAL
Company Name ) +45 /171t. ( /g' i. ,z� Pi/c-
/' ..16:INNER•CASING:OR.TUBING:(peothetinal.elosed-loop)
2.Well Construction'Permit#: `1 If -00 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft, in.
, 3.Well Use(check well use): ft. ft. in.
Water Supply Well:
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in. •
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 04 ft. ZO ft kJ/Ian/Ye /ip,
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft.
❑Aquifer Recharge s ❑Groundwater Remediation
"19.SAND/GRAVEL PACK(if applicable);_ -• • '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) i _. _. ,'-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sorl/rnck type,grain size.etc.)
a O ft. /g' ft. Gl i y
. 4.Date Well(s)Completed:3-Li'Zq Well ID# /e ft / 5 r. brokVil 5l q±C.i
Sa.Well Location: q• v- : 145t. �D it. Fo I IO�n It. R.
Facility/Owner�Na)mee v j Facility ID#(if applicable)ape)�;� ft ft.
z"/,`•Yq7 / yi if../ILC. /U�,/G ide-- i/`!V 5100 I 10( ft ft. I 11
Physical Address,City,and Zip - - ft. ft. t ti-•
.5¢arl/ FS,9 21.-REMARKS. ----:'. • . . . A pp ,` i %iO4 .•
County Parcel Identification No.(PIN) ,,
fIt,:f..-'✓:;...-.':. Jfr/L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4J ."`t
(if well field,one let/long is sufficient) 22.Certification:
35.3y4/7�/ N rD,, Z3cZ3 w Si .3 - zg-'z„L1
6.Is(are)the well(s): Irmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t l o I SA NCAC 02C.0100 or 111 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 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 GW-1 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: Z- t2 (ft)
For multiple wells list all depths ifdii different(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
t �� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Vt') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: ��� (in.) 24b.For Injection Wells: Copy:to DWR,Underground Injection Control(IUC)
J Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4111 Ao /A'11/ 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
(gpm) / Method of test: / Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield mi
1
13b.Disinfection type: / ��I Amount: �,Jy�