GW1--04227_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:• /
Y"1i a;; a r i r r J' ' (�� � !CC C!'f��• 14.WATER ZONES
Well Contractor Name / FROM TO DESCRIPTION _
77 t� IA et(ir/) J cZCk3tO"7 ft. ft. >•
c o3 / /i L �O ft. rt. �/� c� �, v�e�
NC Well Contacts Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap limbic)
C..101Ad•L.. /Th1//t'S 64,C'Ali 22rraillc .. --- /C:. FROM ft. TO ii 3 ft. DIAMETER in. Tlucdlcty �MATERIAL
Company Name /� 1 i-- ` ��e
16.1NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO 51 METER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.U1C,County.State,Variance,etc.) ft. ft. in.
3.Well Use(cheek well use): ft. ft. in.
Witter Supply Well: 17.SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. ' in.
❑Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. - in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Pelrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (,) s ,h v cZ.,`
:Monitoring ❑Recovery ft. R.
Injection Well: ft. I ft
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Test ❑Stormwater Drainage ft. ft.
°Experimental Technology ❑Subsidence Control ft. it
❑Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach nddidoaal sheets if necessary)
FROM TO DESCRIPTION(color.handn soWruck e, in size,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 IL is. ft. sou 6_l� /�n G-' G�
4.Date Well(s)Completed:'S _a/'a?'1 Well ID# / Y it
t f 3 wit. sP;Y 6- ,-e€/ (7L�c-,"iA 4....
5 .Well Location: L.r.3 rG 'I ad• / W 4 y�•-
_! ft. ft.
--c D
Facility/ wn Name Facility ID#(ifapp•cable) fL n• ` • L
/N,710 Cc�nc4,rd PAcif j So (rest,rd U ft JUL 1 Q 2024
Physical ddress,City,and Zip
0 5 . 21.REMARKS '1--cF;611it
County Parcel Identification No.(PIN) 1�'1t g ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lodiongis sufficient) 22.Certification:
35,39t I'5 N 1v ► 63 / Lill W
6.Is(are)the well(s): ermanent or °Temporary Sig f Cetgs
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 I SA NCAC 02C.0100 or 15A NC4C 02C.0200 Well Construction Standards and that a copy
(phis 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 t..21 remarks section or on the back of this form.
p23.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 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional panes if necessary.
drilled: g� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 © C1 (IL) Submit this GW-1 within 30 days of well completion per the following:
For nuthipie wells list all depths if different(example-3@200'and 2®1001
i 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"+"
�J 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC;
t t.Borehole diameter: ` 7 (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: it� f=i''" 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to Eh
(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,CCPCU)
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ©� Method of test: /7 i r
i, ' r; i -
13b.Disinfection type:1 f A •fmount: J s, 1