GW1--06226_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD (GW-1) i 1.,,- ilt:.raga Use Oniy:
1.11 ell Contractor Information: I 1 •
i !
1 05L1 IRe re5 . 14.WATER ZONES I ,
Well Contractor Name C ��,,_,
r I Rtnl , To ) DESCRIPTION
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1. , l(r�-' ft. Pill✓,I
LiI ist 4 I lt. , ft. !(NC ll'e!)Contractor Certification Number ; 15.OTTER CASING(for multi-cased bras)OR LINER(if applicable)
� (UN al Ai-�� l..l s ! I ItU'c1 , IO DIA>IETIIR I THICKNESS j+ MATERIAL
r (I't'L� I fn i ft. I in.
Company Name
16.INNER CASING OR TUBING(eothermnI closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.1<'cll Construction Permit#: .--
List all applicable well construction permits(i.e.WC.('out-.Stan! l'w iuncc.et. i 0 11. 5,0 ft. L)I in. Sc.) Lao `k!`�
l 7 G 7 UV
3.Well Use(check well use): n. rt. in.
Water Supply Well: 17.SCREEN
FROST I TO DIAMETER'. SLOT SIZE THICKNESS MATERLU.
DAericultural EIMunicipal,Public ( 0 ft. /Cb ft. Cf in.I' • pa c 1 Lf 0 °(•
El ieuthcruLtl(Heating/Cooling Supply) 153<esidential Water Supply(single) it. rt. in.
l.)uusu'ialUContntercial Residential Water Sul)ph ( hared( 13.GROUT I
�h'ftg:tion FRU\I 'f0 MATERIAL, EMPLACEMENT METHOD&AMOI'NT i
Non-Water Su lay Well: I
-Pl � fl. �_1(h ft. f�vu��u��� N'OI,U- �� !US 5 S' �
iA4onitoring l eeu'ere ft. U` ft, J
njection Well: i
A. ft.
JAquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery
19.SAND/GRAVEL PACK(if applicable)
Salinit<'Barrier PRO>I I'O MATERIAL EMPL4CF_\IEN'f METHOD
Aquifer Test DStorntwater Drainage 0 n. I PC It. ���� ✓J���
. Experimental Technology Subsidenec Control n. n. h
Geothermal(Closed Loop) JTfacer 20.DRILLING LOG(attach additiilbul sheets if necessary)
FROM TODESCRIPTION(color,hardness,soil/rock time.grain size,etc.)
:Geothermal(Heating Cooling Return) Other(explain under 1121 Remarks) n. ft.
4.Date Well(s)Completed: 43- 5-?1 Well ID# ft. ft. ,
n. ft. '
I unt
1
5a.Well Location:
..o�da C-of It. n.
ft. ft.
Facility/OssnerName Faciht II)-(it applicable, L .i M `, r !"'' )
rS.S"1 i VtL,44)r a I(le Lti Jo 1 1A C- td 7v7S n, ft,
F ((� (j 3
Physical Address,City,and"Lip ft. ft. 0'.-T 2 1 2 V 2T
1.JJ Yr/ 21.REMARKS 'i:l :__
I'aunt Parcel Identification No.(PIN) D'i i.CisIr J
I
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(it',ell l lead,one lat'long is sufficient) 22.Certification'
'S;(1gb5s N '2G . S4iW W v
,gaatii , Ceniliied� 'ell tractor Date
'er 6,is(arc)the well(s) mancnt or DTemporary ;'
�� II:, twin 2 this/nrui.1 herehr cerlift•that thetrelNsl tics(word(co/LrrnNe:1 of accnrefmcc.
El‹.-
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7.Is this a repair to an existing well: Dyes .or .'o • thin 1.''.-1:i '.I('02C.0100 or 1.i.,1:vC.4C 02C.0200 Well Construction Suu;aartis and that a
/,%this is a repair,fill out known well coif.antetion a formcition;rul explain the nature of the cops'of the record has been provided to the well owner.
repair under=21 remarks section or,mt the back of this loaf;.
23.Site diagram or additional well details:
8.For Geoprobe/DP"I'or Closed-Loop Geothermal Wells having the same You may use the back of'this page to provide additional well site details or well
construction_,only 1 GW-1 is needed. Indicate TOTAL.NUMBER of wells construction details. You may also attach additional pagess if necessary.
drilled: SUBMITTAL INSTRUCTIONS i;
9.Total well depth below land surface: 0 ID (ft.) 24tt. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdJ)ereni(example-:'a 200'cold 2ai 100') construction to the foilowing:
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
•
If stater let-el is above casing,use"-- f t 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: ? i 7 f (in.) 241). For Injection Wells: in addition to sending the font to the address in 243
:thin c. also submit one copy of thils limn within 30 days of completion of well
12.Well construction method: iqG tl'1( construction to the Ibllou ing: I •
ti.e.auger,rotary,cable,direct push.etc.) t! I
Division of Water Resources,iiinderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) So Method of test: fti,vir 24c. For Water Supply& Inject-ill) In addition to sending the firm to
t ` y the address(es) above. also submit one copy of this form tnithin 30 (la\. of
13h !I.Disinfection type: T�T l Amount: 9. 11, completion of well construction t 1 the county health department or the county
I_ \s here e lsiriteted.
1-orm(:\\'-i North Carolina Department of I.its tronmeniat Quoins-Dit i.um of Water Resources Revised 2-22-2016