GW1--03845_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Phl b 1 n W. 74,m /e y 14.WATER ZONES
Well Con ctor Name FROM TO DESCRIPTION
2.S o ft. o�'7� ift. /e2 P N,.�
3 s 11-1 ft_ ft. l
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
/� / r FROM TO DIAMETER THICKNESS MATERIAL
/ 1 O n /e� S (ode i I i J►nt/1l f�ij /�7 C.. -r-n• 3? R. (,:by-in. •(+'(O PVC
Company Name (f 16./INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 r](0 gn FROM TO DIAMETER TIBCKNESS MATERIAL
List all a1 licable well construction permits(i.e.UIC.County.State.Variance.etc.) n• ft. in.
3.Well use(check well use): IL it' in.
Water Simply Well: 17.SCREEN J,T A-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. It. in.
[Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
[Irrigation ❑Wells>100.000 GPD FROM TO MATERIAL EMN.ACEMENT METHOD&AMOUNT ,
Non-Water Supply Well: D fL 3 ft• Cal,a11 Y
[Monitoring [Recovery .3 R. r-o ft-if )al.l� `}�c--6,1, ,
injection Well: VV
R. ft.
[Aquifer Recharge [Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) A, PT
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage I. it•
[Experimental Technology [Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
[Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
© it. 3 it. Peek_
g ; f f
4.Date Well(s)Completed:C� 009-0
I
- Well ID# '7�5 �C 31L 3t7 ft- n�_.l✓k_5P�` v1-P l� ll�ty°
5a.Well Location: ft. ,:ns-ft. / „n , /� _.
e `'c rt. I. V� V✓AyL(���llT���
J)t�VI� 1,7/16 Y-
F�accility/Ownerr Name Facility ID#(if applicable) fL h. �- _ -. • f '',
'1i. .z3/if e tot ai/')4) /)x rcrl, J& 3,7s7� iL ft. r '��.�.•1.:4 'VCO
Physical Address,City,and Zipft. fL J U N 2 R 2024
6- oxir1 il,✓ _ 1)%e0ods6'NA. 21.REMARKS
IrrftL:R".A4:C.l ra'r."�OAi::, Urid
County Parcel Identification No.(PIN) _
UM Cr 3t)fti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ! fifi; tor ?
)cation'
3(. /q a�i N 7g- 4-76,1-g W •
D �6.Ts(are)the well(s): Permanent or ❑TemporaryDateih signing this form.I hereby cerr(fl that )was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or 11No 15A A'CAC 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 I 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: A g<5.- (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3(q/200'and 2(Q100') y p
aO 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
If water level is above casing.use"+"//
11.Borehole diameter: (:, (in.) 24b. For injection Wells: Copy to DWR,Underground Injection Control(TUC)
nn Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /+/i?- Iro7 9.ki 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
R Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) iO Method of test: 4 )i
f_
13b.Disinfection type: C')Of')7 e_ Amount: [)O Z
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018