GW1--02574_Well Construction - GW1_20240426

WELL.CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: T
,Te Ffre -1.24c./f er /C�e1C vt'n V 4S/fseii `14.:WATER ZONES : . i'' •
Well Contractor Nime , FROM TO DESCRIPTION
ti &v p- ft.' ft.lc. IL Soy 2 2 iaDJ !So J' 65
NC Well Contractor Certification Number I
15:.OUTER.CASING:(foi-multi-cased`wells)`OR LINER(if ap licablle) :-...':. :
ER
P. . Gfi///,S 14Ae�/ V EI'it; � Itac. 1` I// ft ft. 4d in. THICKNESS•I.2e MATERIAL
`ER C.
Company Name CJ i/OM TO D
/ D � '16:INNER.CASINGsOR TUBING.(geothermal closed loop)- -:
/ •
2.WellConstruction'Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consn•ttetion perrnits(i.e.UIC,County,State,Variance,etc.) ft. ft - in.
3.Well Use(check well use): . ft. ft. in.
Water Supply Well: l7.SCREEN *.:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in. -
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. a 0 ft. t3e r+n//e ,0 ou.-ps'
0Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
'.19.SAND/GRAVEL,PACK(ifapplicable):--a.: - -- :- : -'
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
0 Geothermal(Closed Loop) OTracer ..20.DRILLING LOG(attach additionalsheets if necessary) -- - ..•. -. .
FROM TO DESCRIPTION(color,hardness,son/rock type.grain size,eta)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
�/ !`j ft. /S ft. 2e4 cla�
4.Date Well(s)Completed: / 1o7 Well ID# l g ft• i:"f ft. ea- GAL /0.64-e c.S/ -
5a.Well Location: :,t (,/
/ ft. �,r.00 ft. YtLiete 1�na..0
iitr0-,-7LJ derC. ft a.
Facility/Owner/ NameL / / n J Facility ID#(if applicable) ft ft.
// / y4Q-YY14/'rgi'!•f !t C ft ft.
P
.h
�ys
�ical Address,City,and Zip ft ft. 1.-.' .. ,` ..I . '•I; 9.•; ; )
i//-eckt n h urns- pis--. !7�- A ZI.REMARIGS; _ .
County Parcel Identification No.(PIN) APR () 20 24
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification: U`aC ar t )Q/2O7v
3 ; 376/ a N 8b. 9071L' W ,•,,, '. --7 -c_ - 1a -a.'9
6.Is(are)the well(s):,l�l'ermanent or ❑Temporary Ag*S�e o�-f ied Well Contractor Date
/' By signing this form,Ilrereby certify that the well(s)was(were)constructed in accordance with
7.'Is this a repair to an existing well: ❑Yes or ik'No 1SA NCAC 02C.0100 or 1SA NCAiC 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: U 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
t 5 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
limiter let's!is above casing,use"+"
11.Borehole diameter: 6.N' (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: g0 71...7 t/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) / county environmental health department of the county where installed
FOR WATER SUPPLY WELLSM ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) �J Method of test: (r 1 . Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 141Al Amount: 3 /O t'A 1:5