GW1--04766_Well Construction - GW1_20240812

-WELL CONSTRUCTION RECORD (GWW'-1)
1.Well Contractor Information:
�� Perzss I la.WATER ZONES
Well Contractor Name IRt,yl II) Utz/ RIP tIr
4\'I
.
Well CosuaCtn:'Ccrl:!t,it \:.n. ;' ; iS.01-I I.R(ASING(for multi-cased netts)OR LINER(ifap licable) -1
JfYtA k� ock Or,-
�r t I Iln
. HUMtHUMo DIsvitIItt i THICK�THICKNESSyL 'fERL>L.
�l
It. ft. i in. I
I•ompanc Name I
( (� , t IS Q� ' 16.INNER C_4SING OR TUBING(geothermal closed-loop)
2.Well Construction Permit°: 6 ,}oU `-1 q I.R .I I t(t C DI\1t:It:H IlII('KM'e N�fpclrl/RLA!.
,,:allopplicahla 1rc,/con..tru. .. • . . • �, I't. . (p.s ft. i U in. ). C10 Y V I
3.Well Use(check well use): ft. T ` in.
i
--1 17.SCREENWater Supple Well: - - l
i IRUN ' To DIAMETER SLOT SIZE THICKNESS MATERIAL,
j♦Agriculmu'al oMunrcipahf'uhlic S n. 'tie ft. Li in. , ago `l, 0 PV6.
ii(ieothermal(Heating/Cooling Supply) Eciikejsidential Water Supply(single) n. ft. in.
SI Industrial/Commercial ['Residential Water Supply(share`(' 18.GROUT
•irrigation • FROM 10 MA'!F:RIAl. EMPLACEMENT METHOD&A:1101.NT
o n• I ir)o ft. 6e, kk Ikr la b<5s
■ 17.
1
Injection Well: r-
rt. 1
it.
MI,Aquifer Recharge QGroundscater Rentediauon •
19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery ['Salinity Barrier FROM I ro MATERIAL EMPLACE\IEN r METHOD
$Aquifer Test 0Slornioatei Drainage pc) It. I No ft. .tt� C_t �r -!
NI Ixperinlental technology Subsidence Contra! U. ' it. K J�
fig ['Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0Geothermal(!I cating/C'ooling Return) ['Other(explain under''I Remark.l I I I'"sI ra DESCRIPTION(color.hardness,soils ocA!site.grain+ire,etc.>
It. ft, j
4.Date Well(s)(ompleted: 7-3a- 1 \Neil ilUi i I i $ l' No ft i LLts,,eS ,,ne._
it. ft.
5a.Well Location:
Heary ,,' (C
Vow.
i icui:N UNnar Na- J I acihtN ID-�UtaphLcahl:i 11. 1 n. .,ILD
all l
11�� le), A - 22024
Tu�e� V�0 r1 WC �7�j� 11. 0. . AUG
t'hy.:cal Addrr,. City.and Zip rt. n.
&V 1 21.REMARKS i I,S:.- ..FeeR:e1 A,^7 y ,; 1
I'ounty Parcel Identification No
i PIN.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(t f Ns ell field.one tat long is sufficient) 22.Certification
3S. '33331 N 7b, y39S f
7- 7-at1
6.Is(are)the well(s) Permanent or QTetnporary i •ci IS di Contractor
.. 1/. rui t t .^. i 1 dw1 the -..,,dhv i+crs /irc/ci Car r'cord<inc.
1s this a repair to an existing well: ['Yes or Vo (c 121 ,I 0: I....CA('u C u_'00 Well Cl,n.5,1,1:r1u..:.. :i. d/i anti nx1i:,
,
III/Ns'is a repair fill out known well condlrlcti0n❑7lorinctoolt and explain the noire n11hr ,01,14 of tin..record hiss hecn provided to the well owner. -
11Du;r under-:21 remarks section or on the hock()Phis fr,rm
23.Site diagram or additional well details:
A.For Geoprobe/DPT or Closed-Loop Geothermal Wells basin! the.surly \,tl may use the back of this page to provide additional well site details or sell
construction.only 1 (1W-1 is needed. Indicate'RI! 11 NI \i131 R of Nsclls \."1`Ir1icti,'n details. You may also attach additional pages if necessary.
drilled' 1 I st Mill-FAL INSTRUCTIONS
9.'l'otal well depth below land surface: i f D (it.) 24a. For .(II 'W ells: Submit this form ssithin ,o days of completion of NNel!
1 7;or,Jl,l!..a eli,list a/i depths if diijar-cirt re.rcanplc-:c ' ' ..11.Irlletl.,11 to the Billow mg.
10.Static water level below top of casing: ('(7 (It.) Division of Water Resources,Information Processing Unit.
/r u llc r/eve/rc above Coming.use ' 1617 Mail Service('enter.Raleigh,N('27699-1617
el
II.Borehole diameter: '� (in.) 241). For Iniection Wells: h1 addition to,ending the form to the :+ddre.. m 2 Ia
12.Well construction method: 61Ali•'te_ :.1,,, r.uhinit one cny of this tnrni within 3U days of completion of(Nell
11/ -mutt,,?to the!i'lloump:
U e.auger.rotary.cable-direct push.eh 1
DIN ision ofWater Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: lit L tip 24c. For Water Supply& Injection Wells: In addition to sending the form to
the addresseesi abuse. also submit one coPy of this form ssithin 30 days of
13b.Disinfection type: i-ITH Amount: 9Ibs. completion of well construction to the county health department of the courts .
I \.there constructed.
Form GW-1 North Carolina Department of I.nt11.amrental Nostra-1)1%Nun of Water Resources Revised 2-22-2'i16