GW1--04225_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
\..Yil✓1✓t r/e/l k- / h.., , c-e- 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name �/Lfr. ii i5 h.
203C V7/ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ticable)
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/ FROM TO DIAMETER THICKNESS MA
/1.Cam. ���/�L!// S lIAL
/�/l��►� ,'i ft. V7 ft. 6 0 in. 7.50 G
Company Name �G• �� e
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:CG/1, -L✓C_-ZOZ3I to/6$ 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): ft. It. in.
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Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) pd(esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPIOACEMENTMETHOD&AMOUNT
Non-Water Supply Well: O ft.
46 ft. e -f*L !e !L r
❑Monitoring ❑Recovery ft. ft. //G / T /�
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft, ft.
OExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(cebr,hardness,soil/rock type,grain size.etc.)
0 /5- ft• e- l Ct y
4.Date Well(s)Completed: 6''!L'49 Well ID# /5 ft. 4/3 ft. (f-DIA)h 5 i-e_
5a.Well Location: ..tt if ft. 97 R. q (-.f-e- •
Gibe is rge -S«s‘tc. ` -.hatgaCi1cr C7 ft. boot
Facility/Owner N me Facility ID#(if applicable) ft. '
,
9431 ,�J/e. I-t5 Z,i //t�5ct,,( ,.'C• ft. ft. '1 . .. . - ,/ :�:i -
Physical Address,City,and Zip ft. ft.
21.REMARKS t 9
Cabo.er143
County Parcel Identification No.(PIN) 1,,, , ,,_ 1 ' 'r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.4/NO z zs N SO,'/Z z'/ g /6jt/ ./Ze.. //w6 iLL
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6.Is(are)the well(s): lirmanent or ❑Temporary Signature of Certified 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: DYes or trio 1SA NCAC 02C.0100 or!SA NCAC 02C.0200 Weil Construction Standards and that a copy
If this Is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
,, repair under#21 remarla 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 700 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2®100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 75 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
If water level is above casing.use"+"
11.Borehole diameter: 6%t (in.) 24b.For Inlectioq Wells: Copy to DWR,Underground Injection Control(IUC)
// Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: IC�O � 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 producintt over 100,000 GPD: Copy to DWR,CCPCUA
��J Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 Method of test: Aide-,
13b.Disinfection type: y1-./1' Amount: _Izei/N-11--.0