GW1--03483_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
TeFFreiv Tcccir r•- /Ga v,r/7 Tacks n 14.WATER ZONES
Well Contractor Nam(
FROM TO DESCRIPTION
��0c2. ft. ft. 95l 11 J 02015 a 70
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
�' / ' ,I` f//,�s / �e,G1� Z�� FROM TO DIAMETER THICKNESS MATERIAL
/ ft. 5 Q ft. �g in. * �0v
Company Name
16.INNER CASING OR TUBING(geothermal elosed-loop)
2.Well Construction Permit#: /00 / y oZ R/ FROM TO DIAMETER THICKNESS MATERIAL
- List all applicable well construction permits(i.e.U/C,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): rt. rt. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) fefeesidential Water Supply(single) n. n. in.
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft.
a O ft. Varaort n „ _/
❑Monitoring ❑Recovery ft. ft. d� Y�'�'`"`•"
Injection Well: ft. R.
0 Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness wwrtrck type pram size etc.)
fi
� 0 ft. '10 ft. e C� lG+-t
[/4.Date Well(s)Completed: - 3 a"O2 '1 Well ID# b fL L f 0 ft. Sh,, -- 74Ori e
a.Well Location: ` (� rt. ,r-Q R. ( e
1.i 1C 1Ir�eS i K iMhPr� i'c 4 5 0 r` 3 O oft- 13 et.P G.,..v+.Z.,
Facility/Owner Name Facility ID#(if applicable) ft. R.
O`I /40 lJrf'eF /id it. it. . , , t
Physical Address,City,and Zip ft. ft. ' t
mPrl fJ ter" /,14, 21.REMARKS
County Parcel Identification No.(PIN) ir2.-:;n:..7.1 I"''.aks '� ;,'i
[Y A '-C-v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,on p
one let/long is sufficient) Qj �c 22.Certification:
S Jr / OO / N 0tr c7 75`Q W
���++ ' � . , y -3o-aL►
6.Is(are)the well(s): I�1 manent or ❑Temporary S a Ce Well Contractor Date
� By signing this form.I hereby certify that the well(s)was(were)constructed in accordance with
❑ -
7.Is this a repair to an existing well: Yes or O ISA NCAC 02C.0100 or 15A 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-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
9.Total well depth below land surface: 3 D v (B•) 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')
10.Static water level below top of casing: _7 0 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft:)
"+' Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use
11.Borehole diameter: to /g (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
n Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 D l4t-r'y 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) Method of test: Air
13b.Disinfection type: 147/7( Amount:,3 phi r Its