GW1--05190_Well Construction - GW1_20240903

W Lt LL WINS'1RUCTION RECORD (GW-1) For Internal Use Only:
1.Weil Contractor Information:'TJi r'e7 lic,c4/-er- /C"*vI'r) j-ccC/0-Or 14.•WATERZONES
WellContraactorNam FROM TO DESCRIPTION
'I(Pdp2 ft. It ra �� aso /S
ft. ft.
NC Well Contractor Certification Number
�y� y� 15.OUTER CASING(for multi-cased wells)OR LINER(if ap@limbic)
%/ !/1 cG�/l,,,S IA./et/ ('�l} //tin �y FROM TO+t'.yf ' DIAMETER THICKNESS ! MATERIAL
Company Name r fi c�L l h ( rt.
CeJ ��8in. r r�J iI ��C
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Pergtit#: Nl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG,County,State, Variance,etc.) ft. ft. in.
3.Well Use(cheek well use): h IL In.
Watstel'Supply Well: 17.SCREEN
C7A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�' ❑Municipal(Public ft. ft. hi.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
IL ft. In.
❑industriaUCommercial ❑Residential Water Supply(shared)
18,GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it.
ft,
❑Monitoring ❑Recove 0 ` �--T� ��
r7 ft. IL
Infection Well:
uifer Recharge ft. ft.
❑A
4 g ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage it. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRjj!PT1ON/(rotor.hardness,soli rack type grain size curl
� d ft. e2 D ft. / 'e.Cal C
4.Date Well(s)Completed: C:? "o2.s vv Well ID# �d ft. yl,J Li fL vroc. i 4e ��
_ n .�'hP �
5 .wen Location: li G ft. i_7I Q wit. G9/�e_ G. .-t?�'
c_1-' (ji...„. „6... G,. Y ft. ` Vft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
386j1 NC, ,200 ft. ft.
P {cal A dress,City,and Zip ft. ft.
MI S 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35. 3a gl i N 9 5 t 5 I a4-1) w
6.Is(are)the well(s): ❑ rmanent or ❑Temporary Ss a of C cd Well Conaactar Date
Pe
7,Is this a repair to an existingwell: ❑Yes or Be signing this farm I hereby certify 11mf the well(s)was(were)constructed in accordance with
Si< 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out A7101wt well construction lnJormation and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark section or on the back of this form.
23.Site diagram or additional will details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 15W-1 is needed. Indicate TOTAL NUMBER of wells
drilled: (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
CJ
/� 24.SUBMITTAL INSTRUCTIONS
l
9.Total well depth below land surface: - e 0 (ft.)
For multiple wells list all depths if different(example-3@200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 11 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level s above casing.use"+" ( ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. %g (in.) 24b. For Infection Wells: Copy to DWR, Underground injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RO 71-oW y _ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health deparment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) / 0 Method of test: /9%r p it Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H T/44 Amount: ,3 Pity{ 171