GW1--06376_Well Construction - GW1_20241025

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WELL CONSTRUelfON RECORD (GW-1) For Internal Use Only:
1.Well contractor Informs n:
�r/ &- 64-,r l/1e�)t-
fA WATEICZONES' ✓f�.<,i :7 ._UF,; :Oktg,.3 "t+, .,? , , �A
Well Contractor Name v FROM TO DESCRIPTION
*5-4 5A - ft.
ft. ft.
NC W Contractor Certificationt Number fin/ /q/ 1'S�OURFRCASINCs:(for multi=Casedtwells)',URbJ:INER".(if 8p llca6le)Y`Y.•`
��, I � �I I�I � /�,r�� /'„ ��G I FROM TO D AMETER THICKNESS MfA�TE'R/IAL
n( w I L' «(,,,[([��J, ft. gip ft. �/�/ in, 5J/K2! / V C
CompanyName� / /�y1'6JrINNERy'CASI 'OR;TUBING(peottiermallclosed'-loop)I ° t?,._: `< °i':
2.Well Construction Permit#: 7 A 3 —OD3 I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counts State,Variance,etc.) ft. ft. I In.
3.Well Use(check well use): ft. ft p.
in.
EZ r>-) s :- r:,n1: :.•, i t n, ' 2 �0:�..r '' . ,,;", •, [ .:4t1:?i
Water Supply Well: F F7.,SCREEN a 7.
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. . in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. i i in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i=aIi GROUiIMU,"n .c.,xs:tom ,'e0:.`;r i_',=g .: i': i, .. ' '"
❑hrigation ❑Wells.>100,000 GPD FROM TO MATERIAL EMPLACEMEN METHOD&AMOUNT
Non-Water Supply Well: ft. o, ft. by�iEx/'le 1d l,4-r — /' fJ 5
OMonitoring ❑Recovery ft. ft. V
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ,
i 19eSAND/GRAVEL)PACK.(ifiapplicetile) ` �
❑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 i2ODRIMING L`OG(attactizad'dltionalisticetS•Mireecessary)r Y, ''
FROM TO DESCRIPTION(color,hardness,solUrock tyr,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft q ft.
'4.Date Well(s)Completed: Ll)'--/ e-4 Well ID# it QLrj�' V'dt121 Z-
•
5a.Well L cation: ft. ft.
6i'L f1e N 1/A_(z)YlnzCJ? pivot 5 re of ft. ft. r
Facility/Owner Name P 1 Facility ID#(if applicable) ft. ft. c '_a.-.�,,:r.. . : •1 �
45.5- 7_Ya,xi)))e_uo Y'F'4 .17 Y: ft. ft. , (1(T 1 2024
Physical
Address,sss City,,/1a(n�d Zip o �3 ft. ft.
i Ill-6--�D u el I t.-..1)'.tENIAARI{S(ts,r--n G ..SLA,,__. ; .{:i14i K, gps'`h. , - ,, _ ,o,,
I
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if wellweel field,one
lat/long,/ is sufficient) Q/ Q '/ 22.Certification:
c7�. J (0 7' l N ` O 1 0 q �t -�iYl-W �� ItT/ L ^ �
6.Is(are)the well(s): *Permanent or ❑Temporary Signature a Certified Well Contract 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 L!lNo ISA 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 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: ,A (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example- ( 200'and 2Q100)
10.Static water level below top of casing: gb (fh) 214a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,I1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
/"+'! '
11.Borehole diameter: �P (in.) . 24b.For Injection Wells:Copy to DWR,Underground Injection Control(ITC)
Program,1636 MSC,Raleigh',NC 27699-1636
12.Well construction method: n5lay
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
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) J rr Method of test: Q-/ K'
13b.Disinfection type:(1/Y DtIn�i Amount: i /es-Get 3 •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018