GW1-2023-02793_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD QIEf
For Internal Use Only:
I.Well Contractor information:
N , m,C2 r,, l J/'rt-,her t' APR 10 2023
Well Corurtctor Name 14,WATER ZONES
r.tit FROM TO DESCRIPTi N O�^�i��, d��tlu��� �d b fL �� ft.
Central Office V,6 �
NC Well Contractor Certification Number ft. ft.
15,OUTER CASING for multi-cased wells OR LINER If n licable
FROM TO DIAMETER THICKNESS
MATERIAL
Company Name ff• it. In.
2.Well Construction Permit# 16.INNER CASING OR TUBING eothermal closed-loo
List all applicable well construction permits V.e.U/C.County.Staic,Variance,etc.) FROMft, ^ ft TO DIAMETER THICKNESS
MATERIALMATERIAL3.Well Use(check well use): Z— to �� y 0 V
ft. ft. In.
Water Supply Well; 17.SCREEN
[]Agricultural ❑Municipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Geothermal(Heating/Cooling Supply)Su I ❑Residential Water Supply ft.
t ft• f
PP Y(single) � to ' '"O D Se j+ i/0 V�
❑Industrial/Comrtlercial ❑Residential Water Supply(shared) ft' tt. !n.
❑hri ation PP y(s 18.GROUT
❑Wells>100,000 GPD FROM TO
Non-Water SUpp1y Web; `M,ATERIAL EMPLACEMENT METHOD d AMOUNT_
onitonng a ft. ft. I. e v&v.i1P Pet d fs-6� y
ro,,;t !ow
❑Recovery
Injection Well: tr. fL c-r�C rC /
G�CLLV at y�(U LYJ
❑Aquifer Recharge ❑Groundwater Remediation fL ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ifa licable
❑AquiterTest FROM TO nfnAEMAL
❑Stonmvater Drainage C fr. EMPLACEMENT M1TET110D
❑Experimental Technology ❑Subsidence Corarol t
ft. ft,❑Geothermal(Closed Loop) ❑Trnccr
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooiing Return) ❑Other(explain under#/21 Remarks) FROM 7Y1 -
DFSCNIPTION(color,hardness solUrock ry•pe,prein eixc.etc.j
v © ft. r ft. 9 f
4.Date Well(s)Completed Well iD# u.
58.Well Location:
' ft• ft.
-CG-C- ('hC►r,icr;,�sa�Ps I/C6 003201LZ ft. it.
Facility/Owner Name facility IDN(if applicable)
ft. ft.
ZkS>j ft. ft. E.: �•' {
Physical Address,City,and Zip 7
ft. ft. t-%
_QO r — Q (J y 21.REMARKS --
County
Parcel Identification No.(PiN) ( a••' ji. ;JL
5b.Latitude and longitude in degreeshuiuutes/seconds or decimal degrees:
(if well field,one IaVlong is sufticicnt)
,S 2 q 5,
O �, Z �/� 22.Certification: ^)
C7Permanent or ❑Temporary Signature of Certified Well Contractor
6.is(are)the well(s):
Date
7.Is this a repair to an existing well: ❑Yes or M611, BY signing this form,l hereby certify that lire Well(.[)ivas(were)constructed in accordance with
15A NCAC 01C.0/00 or 1SA NCAC 01C'.0100 Well Construction Standards and that n co/n
repair
Is o repair,fill mr[knonn ire/l consm action iyforrnndon and explain the nn(nrc of the ofth/s record has been pror/ded to the well oinwer.
repair under R1l remarks section or on the bark of ril&'farar.
23.Site diagram or additional well details:
8.For Geoprobe/DPI'or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constriction info
construction,Only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: 24•SUBMITTAL INSTRUCTIONS
/� (fr.)Far nmrltiple ne/!s 11ct all depr/rs rfdereuf(erarnp/e-3Q200'and Igloo) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: - G (ft,) 24a. For All Wells: Ori4ival for! to Division of Water Resources (DWR),
lJlvater level is above.cosing,rise^+ information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11,Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
12.Well construction method:_ �U Program,1.636 MSC,Raleigh,NC 27699-1636
c�f'-
(i.e.auger,rotary,cable,direct push,etc.) - 24c.For Water Su I pqd_Open-Loop Geothermal Returnst1Yells:Copy to the
alt
county environmental eh department of the county where ialled
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Droducina over 100 000 GPD• Copy to DWR,CCPCIJA
139.Yield(gptn) Method of test: Pertntt Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
i