GW1--02563_Well Construction - GW1_20240426

WELL CONST''UCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: /
reFFfe �ac/fer 1 u%Y1 0-2C/Sv11 -`14.WATERZONES i' . • . . ..
Well Contractor Manta . FROM TO DESCRIPTION
Li o ft., ft. 55160 12S1 1309 I"o
ft. ft. .. :I 6.3) 14 O
NC Well Contractor Certification Number 15..OUTER CASING(for wells)OR LINER(if up licable)-
0 c. u l/r S W ea r' vrt C(�•.1 �yG FROM ' TO DIAMETER THICKNESS MATERIAL
Company Name !/ /r +' J ft. I/el rt. / to in. a a C (,/c.
1 , 1 16:3NNER.CASING:OR-TUBIING:(geethetinal closed=l✓oop)?= ::- t/-•
2.Well Construction Permit#: • 14��Ol_11 FROM TO DIAMETER THICICIIESS 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 .I7:SCREEN :
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft in.
❑lndustriallCommercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL--y��- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 02 v ft. VESru P
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation
❑A uifer Storage and Recovery ❑Salim Barrier -19.SAND/GRAVEL PACK(if applicable) • ' -- • :• : - ` '- ..
Q g tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. ,
❑Geothermal(Closed Loop) ❑Tracer 20:DRILL1NG•LOG(attach additional sheets if necessary)'; - : .
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) b ft. f 8 f. e C C�FROM TO DESCRIPTION(color,hars,,soil/rock type,grain size,etc.)
�I �dnessff
4.Date Well(s)Completed:3-/,l-o?"1 Well ID# 1 e? ft. 11 11
ft (23&c-t. `L
3a.Well Location: f::i• 4/11 it. a 0 oft. p:.Ct e ,S cr. - .
\, ��v Ir I.S ft. ft �i((lJ Z �C4.
Facility/Ownerli Name /� Facility ID#( ft
applicable) ft.
6)//a. o CC•••/S 6 rD ve Ad It ft j" .� - :S._.It
Physical Add s,City,and Zip ft. . ft. 3 ham` ^^ F
• 27:-REIVIARKS::: ':,: ,- ,: ...,q..0 /, M9' :L(lt
R
County Parcel Identification No.(PIN) -,J t lI 1'
5b.Latitude and longitud ' degrees/minutes/seconds or decimal degrees: lfr• ;i"'_'`•�'`-}`'
(if well field,one lat/long is sufficient) 22.Certification:
3 5, a a 5 12 N 8o-. 3 6 8 J . W g -� 3 -Ji- a '/
6.Is(are)the well(s): l�Permanent or ❑Temporary a i Ce d Well Contractor Date
�� By signing this form,I hereby cert(that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 4,, 0 1511 NCAC 02C.0100 or ISA NCRC 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 remark.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-I 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
am9.Tottii well depth below land surface: (f•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf dderent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 35 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"=""
8 (in. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: )
D 1 Program,1636 MSC,Raleigh,NC 27699-1636
/I,12.Well construction method: O 1 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /60 Method of test: ry/ r
13b.Disinfection type: 7-64 Amount: 3 p.')174s
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