GW1--06886_Well Construction - GW1_20241118

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
/'
rJ r e, 7�c.c/1'e r / vi v) J c.cfts or) ,<4::WATER-ZONES:. 1..''t . _
FROM TO DESCRIPTION
Well Contractor Na ft., ft. ( 5 3 (O C
6. Da ft. ft. I -
NC Well Contractor Certification Number 15:Oi1TER'.CASING(for:MUIR-cased`veils)!OR-LINER(if'ap livable)
Ve 61 in k e S w tPl/ Wril/i tl� .11/C. FROMTO 3 DI/AMETEK THICKNESS c:.• .
ft. ' ft. LJ/� • S
Company Name ����yy,, 111 16z INNER iCASING:OR:TUBING:(Reotheririatclesed=loop)
2.Well Construction:Permit#: C• i 1-1 -L� )3-�lOtJ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
4 3.Well Use(check well use): ft. ft. 1 in.
Water Supply Well• •47 SCREEN --::-:, . ;; <_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) estdential Water Supply(single) ft. ft. to
❑Industrial/Commercial ['Residential Water Supply(shared)
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. a 0 ft. G °Y � '/�— po.G414
,
❑Monitoring • ❑Recovery ft. ft.
Injection Well: •
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK(if applicablej' . .:.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test• ❑Stormwater Drainage ft. ft. I'
❑Experimental Technology ❑Subsidence Control ft. ft.
['Geothermal(Closed Loop) ❑Tracer :10DRILLINGLOG(attach:additionalsheetelfnecessary)
FROM TO DESCRIPTION(color.hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Ottther(explain under#21 Remarks) O R. u
4.Date Wells)Completed:fa /5 a 9VVeUIl?# ')0 ft. 3 O ft. LC,�yI,../
5a.Well Location: $_ 3 o ft. /J 3 fL Lt:.e ( ,ro„z , •
5 X \ 1 t� Loct_L6-1-- l'13 't. 3 BO• �l4t,P Cam_
Facility/Owner Name Facility ID#(if applicable) ft. rt.
Rant);no Br,aoii Rd. - .
Physical Address,City,and Zip ft.. ft. I
NO v 16 LU/4
t " (et r le S 21:12E14IiARKS :
County Parcel Identification No.(PIN) 5r` •• �,'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
35, a 86173 N So 5S / W ,7 ., /O -45-a 9
6.Is(are)the well(s): l P'ecmanent or ❑Temporary Sfg�ia f C ed Well Contractoi Date
By signing thisfontn,I hereby certt&that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Wes or (alto 1 SA 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.
i repair under#2I rentar/a 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: 0 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 3 C� o (t) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths it-different(example-3 n 200'and 2®100)
l ) 24a. For All Wells: Original(form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3--S (ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: /8 (i .) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RD T1n'at 17 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 lover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 0Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test: I t''
13b.Disinfection type: /{TA( Amount 3 /0 h fS