GW1--03925_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ) /
Well[ Contractor Information:
Q
1 n l R. /l e 0 sle y 14.WATER ZONES
Well FROM TO DESCRIPTION
3c TL I Ss ft. 6a ft. /3 -5)"1 -_s ailetif
`t It. f O 0 ft- .S t 00 - 50,net
NC Well Contractor Certification Number IS.OUTER CASING(for malli-cased wells)OR LINER(if a citable)
ehs(ej's 1Oei1 Di`n !1i ►i (he. Rl+ n 3 n. OtA64/4 n402/ES 0S `tet/CJ
Comppany Name ,
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3L 9 7� I(0'7 - FROM TO DIAMETER THICKNESS MATERIAL
List all a licable well construction permits(Le.UIC.Count.State.Variance.etc.) ft- Lt. to
3.Well(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agri cultural ❑Municipal/Public hi.
a 0) 54ti 4 u otG
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) �� ft- r O '�f Er3
R. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
Olrrigation ❑Wells>100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nan water Supply Well: O ft. 3 B. n„�,- ..1- ems `,(
M❑ onitoring ORecovery 3 ft. �D rt. mrN,I�l 1� �u&y' A.
Injection Well: 1 t
❑Aquifer Recharge OGroundwater Remediation
19.SAND(GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4(9 ft' I Ip.SR- 4?j -- e_vtc( ?p(...k_ -e Cc
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 21.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal Hearin Conlin Return) ❑Other FROM TO DESCRIPTION Color.bandana.sell/rock type.grain size.de..)
( g (explain under#21 Remarks)
O " 7 IL 3fiti °l-rOCk i( t
4.Date Well(s)Completed:n(1(11k Ioli Well ID# 3739 1(09 9 ft- a4 ft 1 r&j l,.Ct fnt-Fc,.
Sa Well Location: o�� R. 1 ft* r J�1 Ll�cyt-. r .,+ 1
T)t'Ir 01-h y -Ta_y toe c s/e l ?�i n SLR R V ` rczrit f e_ t-- 1
J
Facility/Ownerrlame , FacilitylDil(if applicable) , C ft- 60 11 S. .1 a_1,� UL 0 2024
1 I JJt tN-( r kktj I 11,NV ,Rrj a too ._3 -1 nrcLN4te.--Irk):;11.i.PA Air,-sasi�
Physical Address,City,and Zip �D 1L i (5) R 'rT iviC(7fTJ( .e.., }:W•$t;,'
(r^ai 1 k i. 0 3 9 �..-1.. a
County Parcel Identification No.(PIN) I'5 v / s F 1L /r"l j,Tat vi r ---
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `1
(if well field,one hi/long is sufficient) 22.C. "lion:
3to O`-1' ti to 3 N r-1 5 .. :Zt t 9 2 w
27 ram?
6.Is(are)the well(sr Permanent or OTemporan Si _ of eel W Il -ontractor pate
Br signing this form.I hereby cer(h'that the twills)Has(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *No I5A MCAC 02C.0100 or 15A A'CAC 02C.0200 Well Construction Standards and that a copy
phis is a repair.fill out known well construction information and explain the nature of the of this t..u<d has been provided to the well otter.
repair under#21 rented;slktion or on the back of this form.
23.Site diagram or additional well details:
S.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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I(off ft.)
For multiple wells list all depths if different(example-3�y00'and 2 it l003 ( Submit this G W-1 within 30 days of well completion per the following:
10.Static water level below top of easing: o?b (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(Inviter level is above racing use + Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1 6 1 7
I I.Borehole diameter: (c (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program. 1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: R'(R R R
(i.e.auger,rotary,cabk direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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) 40 Method of test eta_
13b.Disinfection typejlat igib ., Amount 0 e-
Form GW-1 (� North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018