GW1--03848_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only_
1.Well Contractor ,1 , , .,,en:
Lk A ./04/ �ua4, 6 2 ,, 1b WATERzoNBs ,
We11CoatractarName _ / PROM TO DESCRIPTION
R3 ti--14/igreol-e,
it. • ft.
NC Well Contractor Certification Number • 15.OUTER CASING(for multi-eased hells)OR LINER GI 6tr)
Malt 1al,.r.� 4, ' FROM TOft. n: DIAMETER . �� ° MATERIAL
tn. I
Company Name .
16.INNER CASING OR TUBING(geothermal dosed-loop) • -
2.Well Construction Permit#: 44 g41-0 FROM TO DIAMETER THICKNESS MATERIAL
List al oppliaableWell caabrudionpe►mits(i.e.WC,Cara) n>c etch=- 4 I ' IL ,i f0 it 4 fa' tj cI, O f' L�
3.Wd1 Use(check well use): :` . 16"' 4f/P $ i f 1 m_ 5 c/-4 t2 p/
Water Supply Well: J U;V () y Z U 13 17.PROSCREEN
DIAMETER SLOT SHE .. . MATERIAL
aultmal• °Muni� �_ "palrn°bh A Rom.. � NUR ,%��- � '°' Leo s/ s5
(Heating/Cooling�g Supply) I ,� `ll.(S it 4- hr.
Olndustrial/Commercial °Residential
( 18.GROUT
°Irrigation °Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welk. C R- • Z/ R N,&p Any/✓
OMmnitoring °Recovery a m
Injection Well:
! R it
°AquiferRecharge _ OGmuodaraterRemediation
OAgoifer Storage and Recovery °Salinity Barrier SAND/GRAVEL PACK MAC /e m MEIBOD
-❑Aquifer Test • OStonnwatcrDrainage A f n- Alp ft �/1 4 (�4 Poiatr
°Experim�l Technology °Subsidence Control ft. ft. O
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach addltiomn1 sheets if cmasaey) . -
°Geothetmal(Heating/Cooling Return) . °Other(explain under/121%madis) FROM TO DlseniP►zorrieamr. maaxlccyp4:�„mshe,etc)
02, It.
4.Date Wdl(s)Completed: - Well DM 0 iz /Ai .mot)*
• Set.Well Location: S 0. , 3U 0. sd StvAsci
Fnalay/owner Fasility1D8Cie) `yo . ,i o.: 1i--<•'/r `
� a
. . . • .. c�/2 • - • • R - ...n .
oo O a a.d z1.REMARKS
Comity Parcel Identification No_(PIN) .
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: •
`n
(dwell field,one latllongis sufficient) 22.C cattier (Q L/YLLi,6 A yell_ A/(4OA
..35 'Q 40- N 79. .3(0 ` S . W, .,4flJ/ -r/iso/z3
6.Is(are)the well(s): Permanent or °Temporary SigpaEone of Certified Wr 1 Contractor Date
Bysigningtli sfomm,l hereby cestifrt at the well(s)was(were)constructed in accordarrcewith
7.Is this a repair to an existing.wdl: - °Yes or t5No ISANCAC 02C.0100 or7SANC C MC.0200 Well Cant vdion Simulants and that o copy
1fthis is a repair,Jill out known well construction information and explain the nature ofthe of this record hasbeenprovided to the well owner_ -
repair onderd2/rmrmlaseation or an the back of this forrn . . 23.Site diagram or additional well detmis:
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 ofwells (add See Over'iRRemarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9 Total well depth below land surface: --Y� (ft) -
For multiple wells list all depths IIfdiferent(example-3@2 and2Q100) - Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: /g (ft) Information Processing Unit-1617 MSC,Raleigh,NC 27699-1617.
!Prater level le-above easing;use^+" •
11.Boreholediameter_ (m.) 246.For Iniection-Wellr Copy to DWR,Underground Injection-Control(TUC)•. .
- • -- -• Program,1636 MSC,Raleigb,NC 27699-1636 . , -
12.We11.construction method: YL(4. //D t/ •24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
Cu®Ber mrary.eab ;dinectpos ,eta)..:... ..... -- - - _- - - - copy en pnmentpTi health department ofthe. h county where installed .. . _.
FOR WATER SUPPLY WELLS ONLY
.. overA
For Water Well's-producing 100.000 GPD:Copy to DWR,CCPCUA• _ .. tPmgram,16111VISC,Ralergh,NC 27699-1611
13a.Yield(gpm) s D. Method of test: r
// J f
136.Disinfection type: /.(�/a.Sy/
/ /10jAmonnk / �r i
FormGW-1 . North(:amliuD mentofEmrammmmlQuality-DivisionofWaterResomms Revised 6-6-2018