GW1--06934_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(GW-1) 4 - For Internal Use Only: '
1.Well Contractor Info ation: • C`t a
•
4�1>;or l k-- 4,4. e �l 1!t
r ✓/G �G � :14:WATER2,ONES . ..1 : . . . .. ._.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well
/JContractor✓Certification Number 15::OUTER CASING(fo multi-caseed'wells)OR•LINER(if n -lieabie)
.d • ,.//7 1/5 t- // dit/L-ch FROM TO DIAMETER THICKNESS MATERIAL
Company Name ,¢1 ft T3 ft /7g In. , 7 fLO I 4/C_
®✓� '.16CINNER:CASING:OR.TUBING:(geothermalclloossed=loop),.. :,f:
2.Well Construction:Permit#: 7 7 0 D '— FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cons:action perinits(i.e.UIC,County.State,Variance,etc.) ft ft. in.
ti 3.Well Use(cheek well use): ft. ft. in.
Water Supply Well: 17.:SCREEN ', ; ,::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft fi in.
❑Geothermal(Heating/Cooling Supply) l idential Water Supply(single) ft ft. in. .
❑Industrial/Commercial ❑Residential Water Supply(shared) .18:GROUT. :-',4--:ir ,,;
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. ? it* r-C ul
❑Monitoring °Recovery ft. ft.
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation
:19::SAND/GRAVEL PACK`{ifappltcable) _ .'
❑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 20 DRILLINGGLOG'(attach addiUorinl sheetslifnetatsary) -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWroektype,grain she.eta)
4.Date Well(s)Completed: it'7 Z.,./Well IN zi ft /'�/ ft. 6/•r,,,w yj Si¢C
5a.Well Location: • E p R' /3 B• 4/tee.- s14t-AC
lGm,..).t.,24,n I.t,Aar/,G,. Ca80-e, 3 n• /6'ft- iI ii
Facility/Owner Name Facility ID#(if applicable) n• ft.
t-L 6r'oiit. • G-/- 9 ft. !t r,
Physical Atddress, /�City,and Zip /� ft.- ft. a ',-.>, °.,_'k.. , ./
j'G�1!ice • /// 21 REMi1RKS;:,`. NOV . 9 2024 . ._
County U Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loong is sufficient) ll 22.Certification:
35.79q zi7 N g0 4i/2 /q 5 W w
6.Is(are)the well(s): 17RP rmanent or ❑Temporary Signature of Certified Well Contractor Date
i
` By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or 171i�O 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fell out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarla 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
9.Total well depth belo}v land surface: 7‘C (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2®100')
t ft: 24a. For All Wells: Original form to Division of Water Resources (DWR),
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10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"++"
11.Borehole diameter: p S'#' (in.) 24b.For Injection Wells:Copy to DV✓R,Underground Injection Control(IUC)
/�
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Zvi/mi�C� 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: ,J •
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /Method of test: /,� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 7T'T Amount: 3 t'7 s