GW1--04560_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 11.7........
1.Well Contractor Information:
ell Q $asp l erson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A ri S'1 H v ft. 3 ft.
a ft. ft.
NC Well Contractor Certification Number 1, 15.OUTER CASINGft. muhl eased wells)OR LINER(It ap 'cable)
h d e r 5 n s dell Dr'r ilia 9 FROMft. TO3 (forDi M$Rin. THICKNES 'cable)MATE$IA//L�
Company Name V � JG.i7 7 -
3 315C �] y 3 16.INNER CASING OR TUBING(geothermal dos -loop)
2.Well Construction Permit#: L FROM , TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(I.e. UIC,County,State,Variance,etc.) ft. fL hi.
3:Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKN S MATERIAL
Agricultural cipaUPubllc 33 ft. 4/3 ft. If ,Ain. LZ Jleaf La P
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in. YI' T�
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL
,/ EMPLACEMENT METHOD& OUNT
Non-Water Supply Well: /^ ft. Le f• 5 4 T E p VY�i i 1.f
Monitoring Recovery vv ft. ft.
injection Well: ft ft. -
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology 0Subsidence Control ft. fL
Geothermal(Closed Loop) OTracer 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.)
.... to ft Otans•SIid CJA7
4.Date Well(s)Completed: OC/ Ziiell Wit I C.
ft ft.
CA,
01-5,
5a.Well Location: "' 2t ft 33 ft. CA- Gr isiCrl
TCrr VVi yn e � ��1ec% 33 ft- y3 ft Why'I-c r3� 54 /VJi
Facility/OwnerName Facility iD#(ifapplicable) ([.
Pam b rb k nit.. 2 $3 72 ft. ft. .... .;.: , '•4fi•-
Physical Address,City,and Zip [ ft f q I /U2 4
RA b e-son `7 !2-o1-O3 21.REMARKS �IJL i' -
County Parcel Identification No.(PiN) -
11.:•i; • a •. _ 5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V _
(if well field,one Iat/long is sufficient) �` 22.Certification:
3 r 3 L 2.2S N 071
, 11.. f/35' W cici,,,jZ
6.Is(are)the well(s) ermanent or OTemporary Signature of Ce ifi Well Contractor D
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: y.� / /� / SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: I(i�v (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
40.Static water level below top of casing: 6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" / 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.,/ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: IQt�-1-w r ry �V^r+ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
/WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �O Method of test: 4:r/1s�# 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�( :.�: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 'f/I Amount:�q ra completion of well construction to the county health department'Iif the county
y` '