GW1--03260_Well Construction - GW1_20230511

AVELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 �1l V T• ' 14.1VATER"ZONES
Well Contmdor Name FR7O.II TO DESCRIPTION
ft. 3 % n.
3�4I
rL R.
NC Well Contractor Certification Number
15.OUTER CASING(For multi-cased tretls)OR LI IER(if ap licable) t
l� t FIt .\1 TO Dl.l\IET R T1nCt:\ESS .11. ERI;\L
Tt t�.Y AO_i.l S PJV Xy Mt 1!C6 `yw, Ct. in. r 0 1
Company Name
z 16.INNER CASiN OR TUBING(tieothermal closed-i p)
2.Well Construction.Permit' FRO31 TO I DL4.\IEfER I TIIIClOMNS I IIATERL►L
List all applicable will cauctntctioa pernits G•e.UIC.Coun(y.State.lrariattce,e1c.) CL n. in.
3.Well Use(chert:well use): it- ft. in.
Beater Supply Well: 17.SCREEN
FROM TO I DL•\d1EI'ER 1SLOT SIZE T111CIL\F_tis lL1TER2.►L
❑Agricultural ❑\•lunicipal/Public ft. IL in.
❑Geothermal(Fleating/Coolin_Supply) )(Residential%Vatcr Supply(single) n_ ft. in-
❑Industrial/Commercial EiResidential Rtater Supply(shared) 18_GROUT
❑htigation ❑%Ve)Is>100.000GPD FROM TO IL+,TERIaI E\IPLICE\SE\T1fECtIOD&,1_\IOLtiT
Non-Water Supply Well: o fr_ .3
❑\donitoring ❑Recovery n_
Injection Well: 3 a'D
❑:Aquifer Rcehare ❑Groundwater Rcmediation CL fl_
( piicablc)
❑ 19.SAND/GRAVEL PACK iraAquifer Storage and Recovery ❑Salinity Barrier FRO?I TO I \L\TERI,\L E,\IP1 C&\IE\T]IETIIOD
❑Aquifer Test ❑StormwaterDrainage rt. fl.
❑Experimental Technolog ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets irnecessary)
❑Geothermal(ItemtinglCDoling Return) UOther(explain under L)I Remarks) FRO37 I TO DESCRIPTION(color•hardness,solfrock_ e.„rain size.etc.)
ft. ft. �'� C� Sa i
4.Date-Well(s)Completed:©`{ �l >7 r�.z3 1\re1(ID ,�, �5 SSA► rt 5 o rL
Sa.Well Location: fit- ' It. �y0� Clt4[k t t^D�L
CC Cushwl #niel, t
Facilit}dO%mcrNamc (,Facility(DY(ifap"plicable) ft- R. it,?
COL 1 1 7023 I
Physical Address,� `City.and Zip r-rV,iD1V l 1 ei 1914 (704,3 '63S7 2L REMARKS Gi> :Cn s' .. •�.r✓,. �
:4'��v
County � Parcel identification No.(PAN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one latllong is sufficient) 22_Certification:
3L0400s (,, �q 11t - P
L i
6.Is(are)the well(s):WPernianent or ❑+emporary ' Signature Ccttified 1 1 .ontracto Date
4r signing this%urn(.I herehv certi&dial the uell(s)teas(were)constntcted in accordance with
7.Is this a repair to an existing well: ❑lies of '*Vo 1-5A NCAC 02C.0100 or/Sa XCdC(13C 11200 IFell CotLvirtectiott Siattdardc and chat a cope
4rdi c is a repair,fill out known trell constriction igforrnatian and explain the nature o{dle gfdds record has been provided to the it-ell oireter
relmir under P21 remarks section or on the hack of tlric lone.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal l ells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
tlrllcd: ti
_ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S ft.
Formultiple tre!!s list all depths if t i(jern tt(example-3@2oo'ra,d 2Ci t►00') ( ) Submit this GW-I vdthin 30 days of well completion per the following-
10.Static water level below top of casing: 02 (ft) 24a. For All Wells: Original torn to Division of Water Resources (DWR),
Ifitwerletel is above casing use Information Processing Unit, 1617 MI SC,Raleigh NC 27699-1617
11.Borehole diameter. (in_) 24b. For Injection Wells:Copy to DWR,Underground Injection Control QUQ
l� !l `f Program,1636 MSC,Raleigh,NC 27699-1636
IZ_Well construction method: fl- P P-O 1-Ak 1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to(he
(i.e_auger,rotary,cable.direct push,etc_) county environmental health department of the county where installed
FOR WATER SUPPLlr 1VELLS ON'LSr: 24d.For Water Wells producing ov 100 000 GPD Copy to D11rR,CCPCUA
Permit Program,1611 itiSC.RalcrJl,idC 27699-F 1
13a.Yield(gpm) �j 1Rethod of test: l `
13b.Disinfection hype: t Amount: I O 0 Z.
Font G11`-I North Carolina Department orlinvironniental Quality-Division orWater Resources Revised 6-6-01 S