GW1--05184_Well Construction - GW1_20240903

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I. ell Contractor Information:
KeIvE
`'> c I K 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ID
ft.
�./�`�'`ft, ft.
NC Well Contractor Certification Number .1
- \ �\ I ` 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
b,,L. , t , i 1 is { 1 kf� 1 i ham-l t t n T FROM TO DIAMETER t THICKNESS MATERIAL
Company Name u ( VV/Vllll/lll��� �1/f 111 ,I�i �L-! 0 ft. 5 ft. Le„P in. o )5 'i�`t�^
��( j Ieiq 0 16.INNER Cut NG OR TUBING(geothermal( closed-loop)ed }�V C�
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In,
Water Supply Well: 17.SCREEN
❑A 7Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMymicipal/Pubiic ft ft, in.
OGeotbermai(Heating/Cooling Supply) esidential Water Supply(single)
ft• ft. in.
OIndustrial/Commercial °Residential Water Supply(shared)
18.GROUT _
❑Irrigation °Wells>100,000GPD FROM TO MATERIAL eti , EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: — ft. ft.' r-
OMonitoring ORecovery ft. ft.
fbr141
ed
Injection Well:
uifer Recharge ft. n.
❑A
q °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.
DExperimental Technology ❑Subsidence Control ft. ft-
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO D SC ii'TtON(color,herd a� orktyke grain eta)
rt. .. () ft. i ,�)� `(`'°tt�r
4.Date Well(s)Completed: SP7 Well ID# %ft. f
ft. J I `'C[l r
Sa.Well Location: ;•t fto,jpeph1/. t�hc f n Lr,C�,sV �)�.(I Lb ft. It. `AA., �'�► 1�_.
Facility/Owt>br Name Facili ID#(if applicable) ft.
i�02'�rrc aces bi-, hcirIc+1r ft. ft.
Physical Address,ess,,�Ciity,sad Zip / ft. ft.
(t / bur3 /9r1' ]ql` 33 21.REMARKS
County Parcel Identification No.(PIN) _
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,ono lat/long is sufficient) _
351 2�^ N �n� 1`11r? 22.Certification: ^
6.is(are)the well(s): �ermanenf or °Temporary Signature of Certified 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 iSA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If Ms is a repah;Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#2i reata•it section or on the back of this farm.
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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTICINS
9.Total well depth below land surface: ft
For multiple wells list all depths ifdierent(example-3Q200?tfid 2 ') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below tap of casing: (VC (.,. 24a. For All Wells: Original form to Division of Water Resources (DWR),
at) Information Processing Unit,1617 MSC,Raleigh,NC 27699-I 617
•
If water level is above casing,use"+'
11,Borehole diameter: `(In,) 24b.For Infection Wells: Copy i O DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Orta/L� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.c,auger,rotary,cable,direct push,etc.) J county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produein over 100,000 GPD: Copy
to DWR,CCPCUA
132.Yield m l'r Permit Program, 1611 MSC,Raleigh,NC 27699-1611
(gP ) -7Cli Method of test;
13b.Disinfection type: 1_I J CI Amount: 1