GW1--05205_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
/
1.Well Contractor Information:
r
,Atli R in[/e 14.WATER ZONES
��tt f FROM TO DESCRIPTION
\VeU Contractor Name
O pry • f1ti J C
3� 1 I 1 IL /0d ft.
-Jfih-
t
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ' e)
\ \ FROM TO DIAMETER THICKNESS MATERIAL
4,0..0 taf2-i1 h , (1► I►ic-- l4_ ft. 4,z�' 6 /i -o zi / Y�
Company Na 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:r?$Ik?p-iI 00A0e-ao, 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits tieWC.County.State.Variance etc) R. ft. to
3.Well Use(check well use): It. ft. in.
Water SupplyWell: 17'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft n. in.
❑Geothermal(Heating/Cooling Supply) )+(Residential Water Supply(single) R. a. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Obligation ❑Wells>100.000GPD FROM TO "ArrFCtr�Al EMPLACEMENTMEIAOD&AMOUNT
Non-Water Supply Well: e) a- ,2-0 ""444'1t E�/10 it-_ ) [lilt
pli
UMonitoring ❑Recovery ft- D.
Injection Well: n. n -
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑aquifer Storage and Recovery OSalinity Barrier FROM TD MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwatcr Drainage D. ft.
❑Experimental Technology OSubsidence 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 DESCRIPTION(calor.hardness.soil/rock/rock aye.grain size.etc.)
It. /D r4 /2 /St?r
4.Date Well(s)Completed:CtlAti..261 Well ID#r5/.IQ-et 02. >-Dz3 .C �C�ZlyeCe- /E) ft. ft. v JJ
7, cock
5a.Well Location: O it. /( RiP IC 411�jtSS
3 L 14,Ett ftSJ Br,ern ��e/ ft. «.
o .
Facility/Owner Name Facility Ifni(if applicabk) ft. B-
// ill k t a t I L411.0 l ec'S'l ' . /4 C� )- .•'3/ rt. rt. I •) 4- '11 4.
Physicalic Addis,City,and Zip r it rt.r.s„„ 0.) - I S'S� 21.REMARKS
11Q
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.C cation-
31'- A7 'F4.3 N 71. 0 6 ran`� W /1/LG 0!) .��/
Paz
6.Is(are)the well(s): Permanent or ❑Temporary
. Sid tun of Xfied Wel ntractor
y�'' By signing this form.I hereby certiji•that the%milts)no(carrel constructed in at..wduna.e with
7.Is this a repair to an existing well: ❑Yes or {iNo 15A IVCAC 02C.0100 or 1 SA MC AC 02C.0200 Well Construction Standards and that a copy
if this is a repair._fill out known well construction information and explain the nature oldie of this record has been provided to the well ouster.
repair under 02/remark section or on the back of this form.
' 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
construction,only 1 GW-t is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: /6 S (ft.)
For multiple wills list all depths ijdi�erent(example-3(u)I00'and 2(a)/0(1') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: aC (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-I617
"(water level is above casing-use"+••
II.Borehole diameter: b (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Program, 1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: .4-JR Qm-74-,C'1 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
? Permit Program,1611 MSC•Raleigh,NC 27699-161 I
13a.Yield(gpm) 7 0 Method of test rl(3.,
13b.13b.Disinfection type: /i4O Amount: ( •C.-
Fonn ti W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6r201 S