GW1--04242_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 JY!PA C r l� etc_.� (� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. 6?-2 rt.
��36 io-2 R. z 0 It.
NC Well Contractor Certification Number) 15.OUTER CASING for multi-cased wells OR LINER f a liable
Au! '/S ')el I ! r+ FROM TO DIAMETER TH-OLNESS MATERIAL
Company Name I�Z fL fL �� m. Z 50 vG
16.INNER CASING OR TUBING thermal closed-loonl
2.Well Construction Permit#: ' FROM TO DIAMETER I THICKNESS I MATERIAL.
List all applicable well constriction permits(i.e.UIC,County,State,Variance,etc.) ft. R. in.
3.Well Use(check well use): fL R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public rL R. In.
❑Geothermal(Heating/Cooling Supply) 911eeesidential Water Supply(single) f, R in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL ENE ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. W R.
❑Monitoring ❑Recovery rt. It.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. R.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK 1'alicableFROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
R
❑Experimental Technology ❑Subsidence Control IL f4
❑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,solwoclr tym VIU Sim ere
ft. It. At _
4.Date Well(s)Completed: (� �a�7�/ Well ID# t o rL (o S rr
Sa.Well Location: 5 ft' 7ICI
Facility/Owner Name 1 Facility ID#(ifapplicable) ft. R•
I'L ft.
._ \ �...
Physical Address,City,and Zip ft. R.
111//J ill
y /�Q 0 21.REMARKS
.-� ti y
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t'
(if well field,one[at/long is sufficient) 22.Certification:
3 N 5?0 , 14L7090 W '
6.Is(are)the well(s): ❑Xrmanent or ❑Temporary Signature of Certified Well 1Wntractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance Will
7.Is this a repair to an existing well: ❑Yes or 1Di4O 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair full 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 ofthis 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: u (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple ivells list all depths ifdtjjerent(example-3©200'and 2@1001
10. 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"%'Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lj
i i.Borehole diameter (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(JUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �-ai 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 0 county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingover 100,000 GPD:Copy to DWR,CCPCUA
7 13a.Yield(gpm) 0 Method of test• Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:_ 117W Amount: /�