GW1--04880_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD (Got-I) For Internal Usc Only:
I.Well Contractor Information:
Bryan McLawhorn I( 14.WATER ZONES
FROM TO I DFSCRIE110N
Well Contractor Name /"''
NC Cert#2061 1130 ft. Li � n. 1 Ake S� c-
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if a bk)
McLawhorn Well Drilling FROM TO DI>MF1I R THIC NFSS SI RIAL
Company Name i�`r�/���0(/_
5 rt. q30 ft. q in, 6r G
j�i ^t �-�✓ V 16.INNER CASING OR TUBING(e.othermal elosedaoop�
2.Well Construction Permit#:--t `A--- `)("1 - ik—A-1°1 FR(tst to titASIFTER THICKNESS MATERIAL.
List all applicable trell construction permits(i.e. WC.C'ourur.State.Variance.etc l Cl. ft. in. `
3.Well Use(check well use): ft. it. io
Water Supply Well: 1 1.SCREEN _
PP Y FROM 1(1 insstl:TF.R 51.01 F: T111C'KNFSS MArT1ERIAL.
Agricultural OMunicipal/Puhlic (� ft. �t�ft. in.� �JL, �.hl/O / ( �,
Geothermal(Heating/Cooling Supply) '(residential Water Supply(single) p, �f H, in
Industrial/Commercial 0Rcsidential Water Supply(shared) 18.GROUT
Irrigation FROM 'TO MATSRIAALL ENPLIACEMENT/METHOD Li AMOC\T
Non-Water Supply Vs cll: G ft. �� ft. /4 fly A f �?f/QC!!Y`f ( /C/!-cJ
stonitoring ©Recovery ft. ft. J
Injection Weli: ft. ft.
Aquifer Recharge �Gn>undwalcr Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO Rl a'tFRI u l su'i>r F stF'Si%IF1'Hon
Aquifer Test 0RecoIn water Drainage fl. /jj,fr� ft. t/ Cl ��� /f L� �)
l:xperinlrrltal Technology DSubsidence Control ft. !/�r/itl�l ft. S� d r
Geothermal(Closed L(lop) Tracer 20.DRILLING LOG(amseb additional sheers If necessary)
FROM lit.) ( IWs(.'RI I'71ON(color.hordncss,soitsocl.ipc,groin tia.Il )
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRO
et. ?,�aJ ft. Yl#(-)
4.Date Well(s)Completed: (t:'- 7 7L/ Well lD# 35 ft. y.7 Cl. e to Y • s. �f•' T i
Ss.Well Location: It. �� ft. 54A)Cil . r-, ?O��
et'i basgi ft- 3/o ft- S�N6/
Facilit •:'Owner Nana ,--�&r..)+f---
r Facility IDA(if applxabk) �a n' ft. y
-�F;lve riA 1wt �.. i. 4 5e - n. yvo r<, c' i, sA�a ,...
Physical Address.(uy,and Zip 480 ft. ikc, ft. SAN
/_,t 21.RREENIIARKSS �p
County Parcel identification No.(PIN) I 4 /I j&M 7, k1 ,. / Ct
aill
AO
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: / 7'4 1 I fit'.` ,aiiPP i/ L,
(dwell field.one fat'long is sufficient) �� � 22.Ce ' ation: �_ e 1
3 `J�/(/p`j7DL7p13 Z 3 C //2- W ,..../..--- 6 -7-: /
6.:stare)the ssell(s) 'crmanent or DTeroporan igmturc C ni tcd ell Contractor Date
Be signing thin flan.1 hereby certify that Me Hell(sl was(Here)constructed in accordance
7.Is this a repair to an existing sell: 01 es or to with 134 NCAC 02C.0100 or 1.1A NC.4C 02C.0200 Well Constnscuon Standards and that a
If this in a repair,fill out known well ransom:nun in/irrnration and explain the nature of the copy of this record has been provided to the well owner
repair under a2I remarks section or on the baei of this ham
23.Site diagram or additional well details:
R.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 1 OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. for All Wcllt: Submit this form within 30 days of completion of well
For multiple wells list all deptlu if different tesump/e-1'a_'O,t an, a I(N)'I construction to the following:
10.Static water level below top of casing: /C/> (ft.) Division of Water Resources,Information Processing Unit,
If water level is above easing.+see-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 16 (in.) 24b.for Infection Wells: in addition to sending the form to the address in 24a
12.Well construction method: ALA
above,also submit one copy of this fonn within 30 days of completion of well
� construction to the following:
I c.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({pm) Method of test: 24c. For Water Suuoly& Injection Wells: In addition to sending the fonn to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constnicted,
t..,,;;i,v:.: North Carolina Department or Environmental Quality-Division of Water Resources Revised 2-22-2016