GW1--06938_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor formation:
�r � ti •
��il i�1�l M ,� r/G.+.. 1;66. 14JWATER ZONES
Weil ContradtorName FROM DESCRIPTION
NC Well Contractor Certification Number
�� . Jf ///S ///I IS.:OUTER CASING_(foi.multi=METE:wellsrO HICKNE(ifap"llcable) -. :......:•• :
1 i t Ih1&( . FROM TO DIAMETER THICKNESS MATERIAL
O 'f.l�_fi. T/r ft. " 34°- o a S' y v ci
Company Name w P
16.4NNER'CASING:OR-TUBING(geothermaieiosed400p).
2.Well Construction-Permit#: Zit' r FROM TO ' DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It ft. in.
., 3.Well Use(check well use): ft. ft. in.
i Water Supply Well: 17::SCREEN'.:.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ..
❑Agricultural ❑Muun�nicipal/Public It. rt. in.
OGeothermal(Heating/Cooling Supply) Dl�esidential Water Supply(single) fa & is
❑lndustrial/Commercial DResidential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD • • FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
'
Non-Water Supply Well: ft. . eL
[Monitoring ❑Recove �� it �7,/� ��TQv kw,
Well: ry Cr. o
ft. D'❑AqutferRecharga ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salmi Barrier 19::SAND/GRAVEL PACK(if applicable): . '.;
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test i ❑Stotmwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer •'2IVDRILLING LOG-(attnch•additlon`al sheets If necessary)
OGeothetma!(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO . DESCRIPTION(color.hardness,soi/rock type,grain size.etc.)
rt. I S' rr• r t 4 C kL V
4.Date Well(s)Completed:/O j/g-'Z�{rell ID# if ft. 36 ft. 9 1s/O.[
5a.Well Location: .. 36 ft 43
ft. nit-e
GA/ u,•aey3 &G 3 ft. dot) ft.
�i r
Facility/OwnerName Facility ID#(if applicable) fL ft. r k,,;'.bn_, ' _:
/O/'.�6. J1',dai
e), /lC)i� l.Jc4)400 ,tc!C, , ft. t is V 1 c L�Z6 .. .
Physical Address,City,and Zip ft. ft. •
464/al-, 0 —10l— art 1,0 21 REMARKS• ►r, ' n-..,
County Parcel Identification No.(PIN) t'1' "`
i
513.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
-W315 N Va7/9a`i3 w .
ro-/g-
6.Is(are)the well(s): frmanent or ❑Temporary Signature of Certified Well tractor Date
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: ❑Yes or leo ISA NCAC 02C.0100 or 15A 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 remar•1r 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2,01 ft
For multiple,yells list all depths if different(example-3®200'and 2®1007 ( ) Submit this GW-1 within 30 days,of well completion per the following:
10.Static water level below top of casing: f(t)
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing.use '+^ Information Processing Unit,160 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells:Copy,to DWR,Underground Injection Control(IUC)
a L Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: It tO7G✓� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,eta 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) 3 S JMethod of test: A✓J?. /a / Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /J 7' 4 Amount: