GW1--05293_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:rPP!o IAel k/k / A.,c), A gIC6 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�0 3 //-0 ft. NO ft.
/yy-ft. ft,
NC Well Contractor Certification Number
�� !// // ///�►) . 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
// // // FROM TO / DIAMETER THICKNESS MATERIAL
Lr /s l � / // 1�'<, -k/kz!L //7 ft 6 Vg in. 2 7C AC
Company Name 3 �} 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Z ` 5C FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,Stale.Variance,etc.) ft. ft. in.
3.Well Use(check well use): rL rt. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) g1R‘idential Water Supply(single) fL ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMP CEMENT METHOD atAMOUNT
Non-Water Supply Well: 0 ft, z0 it t M ciPi iC, rib.
❑Monitoring ❑Recovery ft. it.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test' ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFfRtrnoC loa,o<u soli/rock type,grain size,etc.)
v IL-
L 30 ft, Jll����PP��__CO�CC111✓////
4.Date Well(s)Completed: / �/V`el Well ID# 3o IL /00 ft. p-il 5a.Well Location: /00 ft. //L it 6,ycw t //
SG 401 51/1:41 G
K-✓ur_d G.1t.)425 Omei //S IL /t 0 IL &✓ar+1/-r
Facility/Owner Name Al. acility lD#(if applicable) /10ft• Q IL
Jla.cr S.on .
6/3 /ury r v !/!/G.Y14+� /30 ft 60�t- �i ✓c.,.+ i .. ... -.
Physical Address,City,and Zip ft. ft. i I. N..,L,_: '/l_Ld'
/� 1 06z. Zz-oov� 21.REMARKS
rf ��tJ7f SEPp6ZOZ4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ira^'s'i:r' ii-r.,JA "y ❑ntt
(if well field,one lat/long is sufficient) 22.Certification: IVP Cet2OG
71.00 Sl 3 Z6 N mod• g'Z 1 g6 S W 76- �-� e di 7-- 15- el-/
6.Is(are)the well(s): 1i71'ermanent or OTemporary Signature of Certified Well nnactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or ,J INo ISA NCAC 02C.0100 or ISA 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#2I 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 I 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: b a0 (B') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2®100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: S (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
11.Borehole diameter: 6 2e (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: , ,gat 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
�l Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /. .'...... Method of test: ,41✓•
13b.Disinfection type: /4/7371 Amount: 3 1 iii-x