WI0500448_Well Construction Record_20220104

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For Internal Use Only:
1. WelliContractor Information:
Mqrk
Well Contractor Name
. / P I A
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural f Municipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
igfRecovery
,Groundwater Remediation
tjSalinity Barrier
DStormwater Drainage
DSubsidenc,e Control
DTracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: 7 / ' !3• Well ID# H W - 0 1
5a. Well Location:
icidele..-40-apet,(2
Facility/Owner Name Facility ID#!(if applicable)
9.,,-;41:5 Off`
Physical Address, City, and Zip
1.�. C-11
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/loug is sufficient)
r7 ki t-/W , 9 N 8 ea I'.y
6. Is(are) the well(s)OPermanent or U Temporary
7. Is this a repair to an existing well: [jYes or allo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or an the back of this form.
w
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: IJ x
3.�
9. Total well depth below land surface: � t • (ft.)
For multiple wells list all depths if -different (example- 3®200' and 2@J00)
,�i
10. Static water level below top dosing: A p il�rs� x • Ai (ft)
If water level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: RC ri2.6 .1 ` »' lI i J
(i.e. auger, rotary, cable, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type; Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
?,1' ad ft'
l't J'G ft
j /
�6�8�•�s i -t-'E _ , , /f r yr)
ft.
ft
1
rPI/0,A,/ IA) Cbrc , f70Ae
15. OUTER CASING (for multi -cased wells(OR LINER (if ap heable)
FROM
TO
D1AMEI'EK
THICKNESS MATERIAL
0 ft.
13 ft
'n.
9"-J.). . 40 1
. , -e e_
16. INNER CASING OR TUBING (geothermal closed -coop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in.
ft
ft
in.
17. SCREEN
FROM
To
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
.2.1 i ft-
L17 ft
t/. In.
. 4 f a_
_gal I /S
• s' 4_?ej
ft
ft
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD&jAMOIWF
'El.1t�' . ni . Ci-to
0 ft.
A 7ft
u e - a..-_
ft
ft
gz'of'
s J.x. ft.
G: `/?. ft.
,17---, ,
/ 3 - `17 /.6 c s
I9. SAND/GRAVEL PACK (f applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
*
£t
ft
Alyce- /E' j_ i;y Ni..
20. DRILLING LOG (attach additional sheets if necessary)
FROM
! TO DESCRIPTION (color, hardness, so3Yrock type, gram sere, etc.)
tt''COtia r Sit'i:fir -
ft.
ft.
d� tl ft
'A` ft
C re;ri •e i 6.-tr....., r-, / 17 r -
ft.
ft
9V6ft.
Er,:la ft
Ure" 1 , F.0.7"12,•1 `%f
ft
ft.
j
(/I a 3./c_-( food ,% - Awd--0n
ft.
ft
21. REEMARKS
i_ .�iztL-e.,q_ i-yV Ay�t/�y/ei eet
31{ i ie has-- ?cc:is o 6- (lee- - c...7> 6!a...eil
22. Certification:
ciid e' e€ . get)
.r/wata. eodz:2, cC/45-7/4-
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certfy that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Inieetion Wells: In addition to sending the form to the address in 24a
above. also submit one copy of this form within 30 days of completion of well
construction to the following:
1lfvision of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the fonn to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor information:
Print Form
For Internal Use Only:
Well Contractor Name
..�:7' 9 A
NC Well Contractor Certification Number
AN.e.b )O> G
Company Name
Z i V
2. Well Construction Permit #:
List all applicable well construction permits (Le. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural DMunicipal/Public
Geothermal (1Ieating/Cooling Supply) DResideutial Water Supply (single)
�Industriai/Commercial DResidential Water Supply (shared)
jIrrigation
Non -Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
,Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
DTracer
Geothermal (Heating/Cooling Retum) nOther (explain under #21 Remarks)
4. Date Well(s) Completed: c f
5a. Well Location:
Well ID#
Facility/Owner Name Facility ID# (if applicable)
/ 44-11 z 89
Physical Address, City, and Zip
County
Parcel Identification No. (PIN)
5h. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
�L'43 , 9
N 2c
w
6. Is(are) the well(s)0Permanent or J Temporary
7. Is this a repair to an existing well: QYes or ,gNo
If this is a repair, Jltl out known well construction information and explain the nature of the
repair under t21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 9. Total well depth below laud surface: pprO)r / f (ft)
For multiple wells list all depths if different (example- 3(200' and 2@100')
10. Static water level below top of easing:
"[water level is above casing, use "+"
11. Borehole diameter: 6 (in.) j
12. Well construction method: e ri' n''-"' Y 4)r-i a �9
(i.e. auger, rotary, cable, direct push, etc.)
Approx.. t! ti, (f-)
FOR WATER SUPPLY WELLS ONLY:
13a_ Yield (gpm) Method of test:
13b. Disinfection type: Amount;
14. WATER ZONES
FROM
TO
DESCRIPTION
.),T .
6 -> Gc9 ft.
Zr'r 6, .1 d) r //1 w
ft.
ft
R0,' i%tn /#% Zi?t
15. OUTER CASING (for multi -eased wells(OR LINER (if ap &cable)
FROM
TO
DIAMETER
T1iICl/NESS
MATERIAL
0 ft
7C^ ft
in.
9`.h . Lk
s-_ ,5 e k
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in.
ft
ft.
in.
17. SCREEN
FROM
10
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
loft
4 r0
t:1.. in'
. CI 1 .
gal 15
_,' ie&(
ft.
ft
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
fir. ft*
bp/n4. "'''--
`1i M i''le elt2 i_
ft
ft
,¢
GrLvft-
iLot ti ft-
r5.--- /�-
�2 E �j
t e .. !i T / /:: CCJ..0
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
2... ft
sr�o ft
7
lic .g cave_
ft.
ft.
fiftl z ROIV f y .
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION feeler, hardness, saiyrockipe, grata sae, etc.)
0 ft
2 q f-
n -.�i `
A?t/ +`e-0la P .=i-fit .);,.,
f.
ft
.4.--7, ft.
BIRO ft.
-i o.,lY4.1 ir,1, S: 1 I. SFACQ
it.
ft
'44 9:1 rt-
.6..,: t. ft
?u.; r M iJ ee FL ZcaJti-7
ft
ft
,q
(lt SV& ( 1tia .ray fr.r.v l_'1?r'
%
/ I
ft
ft
j
21. REMARKS
r h p eliet.'57re-,h of
....'vie hay lac ts c) fC ate,--:1 -fr ,.� cC --.? ,3
22. Certification:
(c Cree . _ LC_4.3 <, -
Qd 1
Signature of Certified Well Contractor
By signing this form, 1 hereby term that the wells) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 1SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Print Form
For Internal Use Only:
M4T
1
S
Well Contractor Name
/ / A
NC Well Contractor Certification Number
ReZ G 2 !'i ///;
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
QAgricultural
DGeothennal (Heating/Cooling Supply)
D industriallCommercial
Irrigation
1Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
Non -Water Supply Well:
Monitoring
4. Date Well(s) Completed:
Sa. Well Location:
a.jrd / e- -4P-rr r-0-7
DMunicipal/Publie
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
uSalinity Barrier
DStormwater Drainage
DSubsidence Control
QlTracer
Other (explain under #21 Remarks)
Well ID# (-7 w - O 3
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
(C.A../ / %.:7CCr';,
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
,(1 N 2.3 1�ig%.t►
6. Is(are) the weil(s)0Permanent or Temporary
7. Is this a repair to an existing well: DYes or allo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER oc wells
drilled: J to V a .Lc) tN/'
9. Total well depth below land surface: � ,-,..1/2,,
C ' 'a (ft)
For multiple wells list all depths ifdii different (example- @200' and 2@100)
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: �" f 1 z it 11»e t 1 +el J
(i.e. auger, rotary, cable, direct push, etc.)
Approx, CA)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION/
1 4-30
t44-3)4 ft
t,,.. /
i l l-tze'T b/I!! ch.P; // ev
ft.
ft
`O A I /Y- I 01.4 eft.") CtiirVt a .f?
15. OUTER CASING (for mule -cased wellsR LINER if a
fcable
FROM
TO
DIAMETER
THICKNESS
MATERIAL
v ft-
1.3 0 ft'
' ln"
2s1i . 40
- - 5 4.-e
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft
in.
ft.
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
130 ft
441,(1 ft
Lit, in-
, i) / J
_cell0
s-" `Tit= (
ft
ft.
itL
18. GROUT
FROM
To
MATERIAL
EMPLACEMENT METHOD & AMOUNT
d R-
Y-r ft
EPI +-
feeb? to M -144
ft.
ft
t:fl:
LI). 0 ft
1 ft
.57 E/
f & ((lib ea
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
A .ft
ft
�j
ij
//H*?d
,.azu�'
ft.
ft
/race- f. � -y Mk.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/reek type, grain me, eta)
R.
ft
jr, f0 ft
i k.d-'
tie_ 113yJ 411 rcvs, ei Sc-.+ll"f .6'1-.t,.
ft
ft
s
ft
ft
ft_
f,/t s i/&.i kill}Gjt`,r� �F+N �;(!tiettC/;,ei
/ (
ft
ft
l!
21. REMARKS
``//�� ¢'� y ,r �/�. S
ilk d 4 .r+��-W'�4•'e_ f(if (. eile5ia `f el/' fir„'
22. Certification:
24?Q214-011
Signature of Certified Well Contractor
0 ice Cry ge.o
f
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-i
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
Print Form
1. Well Contractor Information:
mark _ Seder- Sk,
Well Contractor Name
Z769 A
NC Well Contractor Certification Number
RQ.b sbo
ceYrb
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
D Industrial/Commercial
Irrigation
Non -Water Supply Well:
-)Monitoring
Injection Well:
f Municipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Aquifer Recharge IKGroundwater Remediation
�IAquifer Storage and Recovery °Salinity Barrier
Aquifer Test lStormwater Drainage
Experimental Technology D Subsidence Control
Geothermal (Closed Loop) °Tracer
Geothermal (Heating/Cooling Return)) alOther (explain under #21 Remarks)
4. Date Well(s) Completed: L'/ / ICI i11 7- Well ID# H W ° Li
5a. Well Location:
Facility/Owner Name Facility ID6 (if applicable)
rr- >c_ 24
Physical Address, City, and Zip
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one latt//1/long is sufficient)
% 3 '7 Fca ' r 9 N .7�.3 c 8 3 �f
� `
6. Is(are) the well(s)MPermanent or aremporary
7. Is this a repair to an existing well: rjYes or IgVlo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
%1t'tirizoplfa %
9. Total well depth below land surface: APT/U. ,S b t (ft-)
For multiple wells list all depths ifdifferent (example- 33@200' and 2@100)
10. Static water level below top of casing: A Q pro X • 6 ' (ft.)
If water level is above casing, use "+ "
11. Borehole diameter: 4' y�, (in.) �y j
12. Well construction method: i �� �11Vs. U rf ��'
(i.e. auger, rotary, cable, direct push, etc.)
1A
14. WATER ZONES ,Y't 4P 42.AN U r mr
FROM
TO
DESCRIPTION/
` +,sj ft
+' ft
4b
//
1t yr
Zi / ' 1'(S/,4e4.'i ,Zir //
ft
ft
?/Qj r/ Jcs,J1 IA) Cb,1e-
15. OUTER CASING (for multi -cased wells OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
t5 ft
a.11,i 0 ft
in.
9 . 40
5-: 5-fee.4
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in.
ft
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
afO tt.
ft.
in..
a 11.
.7c-65
. 1ee...(
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
3.s ft-
ge ''''"
"" 7e/#1 t`€ M eitiEkt
Ft.
ft
C P"
e ft.
6Co ft
5-12X
ie-.'Gila 8y
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TOp
MATERIAL
EMPLACEMENT METHOD
ii S ft'
st! J ft
*
b i.kez -1 r_t' .
ft.
ft.
frk' e- A.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, sod/rock /rock type, grain etc.)
0 ft
7 Xft-
/Mv a -cob r - 4 �7., C / sisire,
ft.
ft.
t'
I ft-
s va ft
014 Ale i `J', - n-42 rev" ,,r
f.
ft
94 ft
is ts rl ft
ff e
1L.1(1 T wiL '-F�t C,t im mAe
tt
ft
yt'e,
t,/i S�tl:.-i /0,1,i L., /1?4rdG-
ft.
It
21. REMARKS
/��, �,,q
- e i4 &cA tCh f'f' 63C 4 ThA 'i
//p��4!
�(,�rye-
sk si i4? tic 2 6 0 6 g4i.'.o. '-✓ -�1 i4. Cra-
FOR WATER SUPPLY WELLS ONLY:
13a_ Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
(I Id? �Cee ._ �
eta eQ4zzi sb
Signature of Certified Well Contractor Date
By signing this form, 1 hereby cert' that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C.0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Mar*-42,,r-S ,
Well Contractor Name
NC Well Contractor Certification Number
iZeb
sb
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. U1C, County. Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
DMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
]Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
�Geothermal (Heating/Cooling Return)
,Groundwater Remediation
Salinity Barrier
0Stormwater Drainage
Subsidence Control
DTracer
Other (explain under 421 Remarks)
4. Date Well(s) Completed: ^l / /'14 /i T' Well ID# H W " °`z'
5a. Well Location:
Kidd e,
Facility/Owner Name Facility ID#(if applicable)
,r�.
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one latflong is sufficient)
73( 7CJ~ie1 N ,X,3 08.'I-X._
6. Is(are) the wells)
Permanent or 0 Temporary
7. Is this a repair to an existing well: f Yes or WIN°
If this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this fonn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: >' !' Z Ci tr!'tt-1 ? -
9. Total well depth below land surface: ©,P P r(X 3 . b (ft)
For multiple wells list all depths if different (example- 3@200' and 2@1001
Approx . 6 f (ft.)
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: t f 1 , f c -1 43(1(1 1�
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
i+qift
ft
Zire.. b, 1(bid/,v
s-#9c ot.
ft-
Plt, li /f1�r , 1A3 Sl$ ?Dole_
15. OUTER CASING (for multi -cased wells/OR LINER (if ap ►icable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ID ft,
i 8 a ft
i/" ln.
9 , 40
". , `-a
16. INNER CASING OR TURING (geothermal elosed-loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
180 ft,
‘5(.0 ft-
4' in-
.dia..
"d, r t.5
S - Vie(
ft-
ft
in.
18. GROUT
FROM,
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
V ft'
P.,%, ft
EP/ `_._`
r r t`'e me-itiool
ft.
ft-
10a
IL
(c) b 0 ft
v °X
1 e - 4el / ectS f"
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
37 ft-
$ c ft
10
Nfa IPA. j Cam.
ft
ft
%E1 -.. AM/V.1' `
20- DRILLING LOC (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (valor, hardness, miNeock type, arara site. de.)
0 ft
i s ft
^v#., `:-ca!`A r 7 Z J tA.,
C ' ft
' 7 ft
(re-7 , /3 /A..c.4 S-..,T S: 1-1 140 A. Arcs
7 0 ft
a. yo ft.
are,,/le 1 'je..s, nit-, - C6.4 ce
.a t 't) ft'
47 S- ft
C IGt it , Fivve S H 41 C"Ci..-e
SCSS ft
F'A i ft
l ax a/ , S:- /t%f C (r;--1
ft
ft
1✓1 3-1.,v..l ion,'" 4,-; Aesi- a 0;.n.
f.
ft
21. REMARKS
j, f _ A
Ifs -er?4? t.Zc ,F '_ S�[ i et/
3i( Sr it? has: -i,Q'lets 0. ck --.97-...,•a 6Cr, . is
22. Certiflcafion: 0 (C� C o tte+O
eta fod,
Signanue of Certified Well Contractor Date
By signing this form, I hereby cerhfr that the well(s) wu (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Conslructlon Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Envirorunental Quality - Division of Water Resources Revised 2-22-2016