GW1--05825_Well Construction - GW1_20241001

WELL UUINSTKUC;1'1OIV RECORD(GW-1) For Internal Use Only:
1.fWee�ll Contractor I orlm�a/tion• Ac.€
!`y-'/a1'^ �/ Iv��I/,..1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
i.,5 ft. /7 rt.
rt.
ft
NC Well Contractor Certification Number i
/ 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
/e'�d i115 )_ )y l I d,lim<,‹
FROM , TO DIAMETER THICKNESS Mq L.am ,!!! !!! W Ci/ 14/7t. f f. / er in. i L$'O �l�
Company Name 7 v/7�
// 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Z7'jell FROM TO DIAMETER TRICENEss MATERIAL
List all applicable well construction permits(I.e.U/C,County.State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): rt. rt. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. tn.
OGeothermal(Heating/Cooling Supply) t R(sidential Water Supply(single) ft. ft. in.
❑)ndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD " FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ZO ft. ele-A44srle Ple.!
OMonitoring ❑Recovery ft. rt.
Injection Well: _
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer 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) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sell/rack type, tam sift etc.)
AlD IL l' ft. ri.
4.Date Well(s)Completed: 17"/p 7 Well ID# f� ft' 30 ft Az.Az.mO s4,,t
S,,a../Well//Location: :-� 30 IL '/ ft. ,4/t,e $/t.I
trio✓ . 3adtG:::, S/ rt. z5Q ft* p i/
pacilitvl(lwner 1'-me Facility!Di/(if applicable) ft' ft.5.1_ . ,n MCV-50d, git t RA41
ft.
ft.
, ,‘ •
•- Add ,City,and Zip ft. ft . ..
/1/1/0in 0%/00003 C 21.REMARKS ' 11 : )(174
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C
(if well field,one tat/long is sufficient) 22.Certification:
3s 0‘.6-973 N �0y '‘� W ,1a y19-me/
6.Is(are)the well(s): D1i'ermanent or ❑Temporary Signature of Certified Well ntracto Date-
By signing this form.I hereby cent&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®I' ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,Jill out knotty,well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 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-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: Z-6 C5 (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if-different(example-3®200'and 2®100')
' 2 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Stade water level below top of casing: _.1.-- -
00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
' If water level is above casing,use"+"
24b.For Infection Wells: Copyto
I I.Borehole diameter: 6"78v (in.) DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i 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 27699-1611
13a.Yield(gpm) ` Method of test: ,4,-- -
13b.Disinfection type: ldP/7/7/ Amount: _,4•1115