GW1--05270_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
eFFTev /4c4p,- / Or,ccfl Pile e 14.WATER ZONES
Well Contractor iJ5me FROM TO DESCRIPTION
11160 rt. ft. I r Dl / ,O, l 9 0
fit. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
L m���r ` �,�// �}�J� /!I n�� FROM TO DIAMETER THICKNESS MATERIAL
Company Name J GI !! K-L !/ /v j ft. C' ft. 6,),,..6, in. /)v
J' 16. (INNER CASING`J OR TUBING thermal close-loop) /�
2.Well Construction Permit#: 023 ., a (p ,Z. FROM TO LIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U County,State,Variance,etc.) ft. ft. in. -
3.Well Use(check well use): ft ft. in. -
Water Supply Well: 17.SCREEN
❑Aglicnl[llral ❑Mu FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
icipallPublic ft. ft. In.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Li ft. .ryv ft. �.' �-=
❑Monitoring ❑Recovery •?S GIrJGc
ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. [t.
❑Aquifef Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
(•ROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDtainage ft. 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 DESCRIPTION(color,hardness 5niVrock type,grain s ze etc)
- 0 ft. t a ft.
� iio mi «
4,Date Well(s)Completed: /2-30-.:23Well ID# ft. ft. _ A' ��
'PA
5a.Well Location: ft. 3Odr. c� l
.
i \M t G .a I ft. R.
Facility/OwnerNa Facility IN ft. ft. .-.
9/'' H L W e. a. aco ft. ft. t' Is ' ' '.1 I
(
Physical Address,City,and Zip / ft. ft. f.r P Q 2024
{cnlen /\c_3... h`��„`1/.1 lG
13 21.REMARKS
County Parcel Identification No.(PIN) irk( ;,.,-,4,i,:C i1 ' .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: aY`
(if well field,one Int/llo /o�nng is sufficient) �j ^ 22.Certification:
Li ° '3� GDY N 60 . mG '73/ W
ice-4--- /2_3 0_,2 3
6.Is(are)the well(s): rmanent or DTemporary of riffled Well Contractor Date
By signing this form.I hereby cert fv that the wells)uas(were)constructed In accordance with
7.Is this a repair to an existing well: DYes or ififi'' 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out 672oeot well construction it!formation and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary,
drilled:
24.SUBMITTAL IN.
9.Total well depth below land surface: 3 D o at.)
For multiple wells list all depths iidifferent(example-3@200'and 2®100') 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: 3
If water level is above casing,use" Lift) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
11.Borehole diameter: ) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
�q (in.
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RD 74ci:ry 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
13a.Yield(gpm) 5 �Q Method of test: /. %r i Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: / / /I Amount_ 3 !J j rI'7'5