GW1--05279_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information: Ii
V'ekV'' e1\ V t to "J es-C k S G h 14.WATER ZONES
Well Contractor Name `` FROM TO DESCRIPTION
b �.�,��[t R.�..°V
NC Well Contractor Certification Number 'v b V R. 32.0
s. `• 15.OUTER CASING(for mull(-cased wells)OR LINER(Hap Usable)
‘ L.,, 14\1/4)W 5 ,,,1‘ r-,1 0}.^ FROM TO DIAMETERTHICKNESS MATERIAL
Company Name f� • ^l ,--% rt. I ti S n f & i at. f y l.. " PVC
2.Wei!CoDstrnclion Permit : J v�j 6 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well canstrui'lIon permits(i.e.UIC,County.State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): R. R. in,
Water Supply Well: 17.SCREEN
❑A iCnituml -FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
>P ❑MunicipalPublic IL ft. In.
OGeothennal(Heating/Cooling Supply) 'Residential Water Supply(single)
R. 2 In.
0Industrial/Commercial ❑Residential Water Supply(shared)
IL GROUT
❑irrigation ❑Wells>100,000GPD . FROM TO MATERIAL ` EMPLACEMENT METHOD&AMOOFiT-
Non-Water Supply Well: 0 ft. 2-1Zy ft. 'D r ei' p 4 fac-f❑Monitoring ❑Recovery IL ft.
Injection Well:
R.
❑Aquifer Recharge ❑Groundwater Remediation R.
❑Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage R. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets ifnecessary)
DGeotherrnal(Heating/Cooling etu ) ❑Othor(explain under ii21 Remarks) FROM TO DESCRIPTION(color,bardnau IoWrocrc type Endo size•eta)
1 u Co a I0 ft_ ram( c. wy
4.Date Well(s)Completed: f L{,Jy Well ID# ID •ZO h / _ 1
Sa •
QWell Location: , 1 nr� �� R. 6 V�1�CiS59Q�lib�
- c'% k S Wt/tkc+- ft. ft.
1�.�
Facility/Owner Name 1 s Facility ID#(if applicable) f4 Q. { - t -
Physical Address,City,and Zip Ct ft. J E P 6 ZU ZQ
1' `►GkeN h/ • ' C 6C, 2l.REMARICS.
County Parcel Parcel Identification No.(PIN) (t i�fl:T.'il f it ",yltii.',+�;Mil'
DWC6 1013
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
:35 .3r1q 2- N 80tV9Ir1O W H41244
4
..
6.is(nre)the well(s): ItlPermanent or °Temporary Signet of`ert`fied Woil C r pat
By signing this form,I hereby certify that the weU(s)ens(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or alNo 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information 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 fawn.
23.Site diagram or additional well 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 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 INSTRUCTIONS
9.Total well depth below land surface: 4 on
For multiple wells list all depths ifdtl(farenr(e ample-3©200'and 2(aj100� (ft.) 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: 0 VL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,use"t"
11.Borehole diameter (7 I (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
AProgram,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I't 1'C"• 11- CA
(ie.auger,rotary,cable,direct push,etc)
For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Co to DWR,W12.CCPCUA
13a.Yield(gpm) 5 Method of testA k r Permit Pro gram,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: 141-%rk Amount: I %ii-t4