GW1--06937_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ? •
1.Well Contractor Information:
ZfsIIJ)•vt / k. A-,Gi..- y!G e.. `14:°WATER ZONES.,>>; :. i. -
Well Contractor Name FROM TO DESCRIPTION
z_o3 6 9S ft., 114 ft. 1
/ p n. ft. 1
NC Well Contractor Certification Number '
7//r / y,�Jw/j/J, l [ II 15.OUTERCASING(formulti.eaSedwells):ORLINER(ifaplicable)
/•C i r/'/t l`1 e / 1 /��yl FROM TO DIAMETER THICKNESS MATERIAL
. Company Name �1 it 5�i ft 6 in. ,ZOO AvG
�/ 16.•INNER:CASING:OR;TUBING(geotheriaetclosed400p)
2.Well Construction Permit#: �7 �Z�v FROM TO DIAMETER TIUCIQIESS MATERIAL
List all applicable yell construction permits(Le.UIC,County,State,Variance,etc.) ft it. I, ' in.
.. 3.Well Use(check well use): ft ft. In.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) residential ft.Water Supply(single) n, ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.;GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EttLACEMENT METHOD&AMOUNT
`
Non-Water Supply Well: 0 ft* SZ ft ‘^7 Jl41/k Al
❑Monitoring ❑Recovery ft. ft
Injection Well: a
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier FROMND/GRAVEL PACK`CMATE icnble) ._ ,. .
tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test i ❑Stomiwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. '
❑Geothermal(Closed Loop) ❑Tracer •20:DRILLING LOG(attach additional§heats if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness sowrock tppe grain size.etc.)
O ft. 5 ft. led 1
. 4.Date Well(s)Completed:/6''ZJ'2/Well ID# S ft 3 5 ft' �A�✓�..)vi 3444.,k,
5a.Well Location: , 1 :.,' 4.z..
34ft. y'Zft' /5l G e
One, /!c of- U1_42 1/td.3 7 Z ft 340 ft. , /) ' //
Facilityy//OwnerName Facility ID#(if applicable) ft. ft.
. co, c %�Il 1.rX. ft. ft. E t .'
pY r+M G M1.-- R a 5 ' -
Physical Address,City;and Elp �/J / / . ft ft. } ""
tdllt f/'/S�lt,Z''r..�f{3r5 z1:REnIAltxs:'. t :1:V011 : ::LO/tl
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �' .«-=` ;,3
(if well field,one lat/long is sufficient) I
3 I,O���/ M / 22.Certification:
N ?i �� y7GIUD" W •
7 • /0-13--el
6.Is(are)the well(s): 13)sermanent or ❑Temporary Signature of Ce 'fled Well Contrac or, Date
I,
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: .. %s or glie ISA NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repel::fill out know,:well construction information mid explain the nature of the of this record has been provided to die well owner.
, repair under#21 remark section or on the back of this form.'. ` 23.Site diagram or addiNonal 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:•
024.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3GC,
ft Submit this GW-1 within 30 dais of well completion For multiple wells list all depths different(example-3 rQ+200'and 2(4)100) Y P per the following:
if
I'
10.Static water level below top of casing: /�'� ,,, . 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing.use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: /g (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
y Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /t'D
"4—( 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,eta) l) 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
//fJ •
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 Method of test; .FJ)✓ •
13b.Disinfection type: lir/7 Amount: 4"),,d-e