GW1--06914_Well Construction - GW1_20241119

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: ' '
1.Well Contractor Information:
CAA V\0\\�s / 3,\\1 �s�;w '14cWATER-ZONES i : . .Well Contractor Name FROM TO DESCRIPTION
ra�'�c\ ft a()ft:, ant
ft. ft. I
NC Well Contractor Certification Number
15::OUTERCASING(for:multreasedirells)`OR7;INER(if'app-Itcable) ,..
•L• C,yj\\1 S �l1 G\\
�J I:
tea a l -C, FROM TO
ft. ft. DIAMETER in. THICKNESS + MATERIAL
Company Name V ,.
��I ��^ ;16 INNER CASING:OR. UBING(t eothermal dosed=loop)
2.Well ConstructionPenFit#: ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable welt construction permits(Le.CIIC,County,State,Variance,etc.) \ ft Sl-, ft (',1% in- .'a S P V L
4 3.Well Use(check well use): ft. .ft. I in.
Water Supply Well: 7:SGREEN ::_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunici al/Public ft. IL i•in.
OGeothermal(Heating/Cooling Supply) 'l residential Water Supply(single) ft. ft. ,in.
•
❑industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT;
❑Irrigation ❑Wells>100,000GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (ft ra Oft' .a... 2vul_ea
❑Monitoring ❑Recovery ft. ft. 9 •
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
.:19.SAND/GRAVEL`PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD }
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer • •: 0 DRILLING LOG(attach:additionatsheets ifnetetsary) __
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,soil/rock type,grain size.etc.)
Q ft Q.O ft. "34 tJW J C`4"/
4.Date Well(s)Completed:\t ti3'a`\ Well ID# a c ft 5 V rt 9,41.4.) AvI 4
5a.Well Location: ez,$ s(p ft. 3Vp f. eijka,c Ape -
5b.a C�inc s tic L cn4 5 ft
Facility/Owner Name Facility (ifapplieable) ft ft. ` -'' J};,L_n .
‘�4o1 Cc -C ?5 • ft. ft. , _ .__ -.
Pit'ysi I Address,City,and Zip ft. ft. it N O V 1 C U 24
' a��' `' d..� - �� 21 cREMARKS:,: J g4
]ram
County Parcel Identification No.(PIN) 1.. -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
�
(if well field,one let/long is sufficient) 22.Ce ' ation:
`\S,vr‘$1'ZL 0 N '-% 0\.CV\a90 W
6.Is(are)the well(s): �Yermanent or OTemporary Signature of C . /0-3-(D4
ed well Contractor Date
I _ ) By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or o ISA NCAC 02C.0100 or ISA NCAC l)2C.0200 Well Construction Standards and that a copy
If this is a repair.fill out brown well construction information at 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*ell 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: 3 (ft") Submit this OW-1 within 30 da completionper s of well the following;
For multiple wells list all depths if different(example-3©200'and 2tu 100') y
1 24a. For All Wells: Original formto Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,161'7 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"r+"
11.Borehole diameter: ` o (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
� � Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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: S
24d.For Water Wells producinE over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) t\ Method of test: '�k: T` _ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1^� \ Yt Amount: eLlN T3