GW1--03191_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
e e.CCI i�Qtc.0 14.WATER ZONES
Well Contractor Name FROM TO UESCR1rT1UN
•
a4o� -A ° rt. � rt. c-�l•CtUe.<<<-�Y
NC Well Contractor Certification Number It. /_ H, <i0.1
15.OCTER CASING(for multi-cased stells)OR LINER(if ap licabk)
MILLER WELL DRILLING FROM TO DI A,IF•1ER I THICKNESS MATERIAL
ft. ft. I in. i
Company Name
�/� 16.INNER CASLNG OR TUBING(geothermal cloned-loop)
�•�,
2.Well Construction Permit 9:l J�l(n(� 11j 73 FRn`I TO nI.1METER THICKNESS SISTERI.AI.
List all applicable well construction permits(i.e.M.County.Stutz.Variance.etc. ft. ft. in.
3.Well Use(check well use): ft rt in.
Water Supply Well: 17.SCREEN
FROM •It) DIAMETER SLOI SIZE THICKNESS MATERIAL
❑Agricultural Municipal/Public ft, ft. in.
OGeothennal(Heating/Cooling Supply) v�esidential Water Supply(singlet ft. ft, in.
❑Industrial Commercial GResidential Watet Supply(shared) la.GROUT
0irrigation ❑Well,>100,000 GPO FROM TO MATERIAL EMPLACEMENT METHOD&AMOLNT
Non-Water Supply Well: Cj ft. .3 ft.
eQ,:\--/....„4 pLA.,,re A S. ,c;t:J.,s
OMonitoring DReeover} ft. fL
Injection Well:
ft. ft.
ElAquifer Recharge EGroundwater Remediation
t9.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ESalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
°Aquifer Test =Stormwater Drainage ft. It. I
°Experimental Technology 7Subsidence Control ft. H. •
OGeothernial(Closed Loop) GTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cuoline Return) °Other(explain under;i21 Remarks) FROM TO DESCRIPTION(color.hardness sMYmck npe.grain Bice,crest
Q ft. 5✓� rt. 6 uC-\ /C to. I-` ✓ y p'�Y
4.Date Well(s)Completed:5-0 26).4 Well iD# 3 crl• , .. ft. Si 0,4-e /
Sa.Well Location: S •
0 rt. L s-ft. C i�.k era.c.L '-tA - JpM
�(/+t\r1t� ,.t ( ft. ft. J i
s `J 4 rys �c :Ar`-C. ti
Fac::lity.Owner
t\\ame Faciti:y ID*(if applicable) ft. ft.
1 e + I LI C re_e r.;Ae_ ACeQs a Q)esE,l►tC tr. ft.
j r`
Physical Address,City,and Zip ft. rt. E `ti...4,,•L..I,i/ '1»" + )
Ci.q-. - ac'04 54ac)o('�soa i 3� 21.REMARKS MAY 2 c 2024 SJ
County f - Parcel identification No.(PIN)
Ilvit
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ifl`J±l' A'f:: ;o r. :140" ^a�Of well field,one tat/long is sufficient;
311 , 9
�n ` 22.Certification: D'fr;," j0
6.ls(are)the well(s): ermanent or ❑Temporary Sl wtJre of Co-tidal Well Contractor Date
Bc signing thisfornt,I hcrcir ccrti/i that the n•ell(si was(were,constructed in accordance with
7.is this a repair to an existing well: CYes or ._:No /5.4 Ana'02C.0.,O)or 1.S•I.\'C:4C 02C.f20.7 Well Construction Sutmlarrls and that n ropi
If this is a repair.fill out mown well construction information and explain the nature of the of this record has keen provided to the well owner.
repair under*?i remarks section or on the hack of this Iona.
23.Site diagram or additional well details:
11.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:
24.SUBMITTAL LNSTRUCTIONS
9.Total well depth below land surface: (D,S (ft,)
For multiple wells list all depths it difrrent(exam/1,--;raNjs) and?!a IOW)
this GW-1 within 30 days of well completion per the following:
(ft) 24a. For All ',ells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
if water level is Whore casing,rc.c•-" Information Processing Unit.1617 MSC.Raleigh.NC 27699-1611
11.Borehole diameter: W (in.) 24b.For Injection Wells:Copy to DWR.Underground Injection Control(11'C)
Program. 163o MSC.Raleigh.NC 27699-16?6
12.Well construction method: A\c Qo{d(-/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
(i.c.auger.rotary.cable circa push.etc.) ( coumy env:romnental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD: Copy to DWR.C'CPCU.A
13a.Yield(gpm) a '' Method of test: 1.s Permit Program,1611 MSC.Raleigh.NC 2'.699-1C.:1
13b.Disinfection type: 4-•i 4�� Amount: i R i7 Cam,"_ •
'
Form O W-I North Carolina Department of Env�ironnmental Quality-Division of Water Resources