GW1--05199_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
j-FF '' 7 c/rer fGOL(1/r1 Za C/LSD r7 14.WATER ZONES
Well Contractor me FROM TO DESCRIPTION
110 O ft. it.
t Jc ( .5� / 1 D l 75
rt, rt.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(If ap Ilcable)
Vi /'•r MC///!C �eli Prill/f'l /�� FROM TO DIAMETER THICKNESS MATERIAL/�
Company Name !/ J ( i • -1+/ rt -7 /J ft. /_4�S in. o n C !'!/C
�t / 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• i 0 qL 'm &i g 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LiC,Coun, tate,Variance.etc.) 4, I ft, 'Is ft. y N is im.v Pdc
t 3.Well Use(check well use): ft. 7 rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OM/un�icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. In.
•
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
2 Non-Water Supply Well: 0 ft. ,y /.7 .t, _ . se CI❑Monitoring ❑Recovery ft. rt. ��4
Injection Well:
ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test, ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
❑GeothermalFROM TO DESCRIPTION(color.hardness,soil/rock type,grain size,etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) v ft. , rt. ed 1 j
4.Date Well(s)Completed: U` -� 1�
D ell ID# / ft. (./' ft Pet •GC /
A",..- ie(ic e t is,
5a.Well Location: :.‘ ilq II.
`of o oft. e7'G/u ft. ft.
v-er o r)1 cct. J 5 f - P _
Facility/Owner Name Facility I (i applicable) ft. ft.
,3/o Ep,•erson Rd. ft. R.
Physical Address,City,and Zip ft. f. '
Ro w a.n 3 3 0 / 5 a. 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:
,3s • 7 a 0 ? '3 N SO4 .5 11142 9' g W
0 -ao-ate!
6.Is(are)the well(s): tmanent or ❑Temporary Si t ern ell ontracror Date
f By signing this form.I hereby certifythat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ISifi !SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#2l remark section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 4024.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a O Q (ft,) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2( 100')
' e 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �13 7 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-I 617
If water level is above casing,use +"
/ '/
11.Borehole diameter: ( / ' (In.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: R O/1 mac'}/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
A t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) e, S Method of test: it( r'
13b.Disinfection type: / 7 l T Amount: 3 /%n 7-s