GW1--06936_Well Construction - GW1_20241119

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
(4CL � /! . A -LE IiGe...n Ace,
Well Contractor Name FROM TO DESCRIPTION
Z035 _ O'ti ft.: f� ft
�S/o ft rt.
NC Weil Contractor Certification Number /� I J' 15::OUTER CASING`(for inult►-cased.wells)":OR LINER(if ap pliable)
. /. A/44 A S I ) ) I ,/ �r///ice FROM TO DIAMETER THICKNESS MATERIAL
Company Name /" LK.� 0�/ / #/, fL ei,e, ft. 4 Aiv. .in. o Z5
16rINNER CASING:OR:TUBING(geothermalclosed-loop) ,
2.Well Construction Permit#: Zy ..3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC.County.State,Variance,etc.) ft ft, 1 in.
n 3.Well Use(cheek well use): ft ft. !. in,
Water Supply Well: fit SCREEN _ . : ":: :-> .. #.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) liafsidential Water Supply(single) ft ft, In. .
°lndustrial/Commercial °Residential Water Supply(shared) ",'18 GROUT "`
❑Irrigation ❑Wells>100,000 GPD . FROM TO ATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft "ZO ft, cbg e ,,111; .
❑Monitoring ❑Recovery ft. ft a
Injection Well:
❑Aquifer Recharge °Groundwater Remetiiation ft ft.
i
'19:SAND/GRAVEL PACK=(ifapplicable) -
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test, ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer i20 DRILLING=LOG'(attach additional sheets-if necessary) .
FROM TO DESCRIPTION(color,hardness,solurock type.gain size,etc.) .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d ft z4 p, it. 5,, i�� 0
4.Date Well(s)Completed://-://"C�J/'Well ID# Z Z 4`ft % 1
5a.Well Location: i;4. , -�5' ft. ft. gire�.cid
Facility/Owo.e Name Facility ID#(if applicable) ft. ft.
3q%'C� C. :eeen e Ed, i'//�✓G t: ft. ft' t � �. , 4...,, . .,.,
Physical Address,City,and Zip ft ft.
• �j Z/ j NOV„ 1 n 7024
sitext^ Off —03 —1 /S,/� '21c REMARKS:i
County Parcel Identification No.(PIN) I ...:r.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneelllaat/long is sufficient)
C 22.Certification: ` ( `�75./,v q�(� N Va ye/O f ie W sJJ I—L f_a 1
6.Is(are)the well(s): Wrermanent or ❑Temporary Signature of Certified W Contractor', Date
By signing this form,I hereby certl&that the well(s)was(were)constructed In accordance.witli
7.Ls this a repair to an existing well: ❑Yes or Itleili ISA 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.
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 OW-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: ( )
For multiple wells list all depths if different(example-�r}OD�d 2®100) ft' Submit this GW-1 within 30 days of well completion per the following:
1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 34!) (it) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
11.Borehole diameter: 7( (in.) 24b.For Infection Wells:Copy,to DWR,Underground Injection Control(RIC)
���� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: .s f�-/
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
13a.Yield(gpm) 'c.• Method of test: ,/f)✓ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /4 1711/ Amount: ./AN.,.S