GW1--04186_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information,:
/444- n) .,,Eta_'4^- A—+zK 4 Ate--1,- — IL WATER ZONES
Well Contractor Name FROM TO DESCWEIION
IL IL
Nc Well ComradorCertifirauonNumber _ IS.OUTER CASING(for mnitbnaal wells)OR LINER Cd�PQ )
•
g . L_GC FROM 1n DIAMETER + MATERIAL
!!//��// IL ft. 1In'
CompanyName -
r1 16.INNER CASING OR WRING(geothermaldosed-loop) -
2.Well Construction Permit if: /.$ 'e-3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cmrstrttctionpermfts(i.e.WC County,SYatc Variance,etc) '4-/ IL 444 Iti 1n' SCA-'i/O PyI-
3.Well use(check well use): - '`// IL 11 4' m SCE- S/O 1 v
Water Supply Welk - 17.SCREEN
FRO
M
ival TOq DIAMETER SLOT SIZE TRIMNESS MATERIAL
R]AgnCrdt OMtmitapal/PaibliC &/O // AT 1m 66 J 0 55
OGeothermal(Heating/Cooling Supply) J*esidential Water Supply(single) ft. it. In.
Olndustrial/Commercial ❑Residential Water Supply(shared) is.GROUT
Oluigahon [Wells>100,000 GPD FROM TO MATERIAL EMPLAcRMENTMEfIroD&AMOUNT
Non-Water Supply Well: Q tt c2 f ft /1/ N/5 Pu)u
[Monitoring °Recovery R ft.
Injection Well:
Aquifer-Recharge OGcoundwaterRemedielion It.
O
19.SAND/GRAVEL PACK-(dapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ERIFLLACEMFRFMEIEOD
°Aquifer Test OStomiwater Drainage °cj•/ IL i73 !L 14- j4a a P j
❑Experimental Technology • °Subsidence Control It ft. C11
oGeotheinial(Closed Loop) °Tracer 20.DRILLING LOG(attach addltional sheets ifsmssary) .- • •
❑Geothermal(Heating/CooingRet�) °Other(explain under 1121 Remarks) FROM It) DFst�lION(mmrlmaeea+.snwroct sue,etr.)
�y 0fi a,aIL A -e/
4 Date Well(s)Completed:Obi./g/93 Well ID# 4. 41�7 a 0 a- 7/ It G lv 4-4 .00e-G/
Sa.Well Location: i/ EL Re? It .%0)-i-d I- ez&e7nex r/
Fmiity/Owner Name FaclityLW(rfapplicable) IL ft'
PhysicalAddrar iry,and A. °a '/37 G IL It
1YL ooa a i9 21.RE117ARS5 i�i► !1 2023
County Parcel Idatification No.(PIN) - •
,. ^ I n
Certification:
Sit.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one Wong is sufficient) 22. Li ern•...Q ! a l.,cbt=e..._ c 3 72->
5s�l6 ` �'' N 79 °,3e ' `s,- W � ,D AAci-Lc� I q??-e- ilL7A?9/2_3
6.Is(are)the well(s): ermanent or [!Temporary Signature afCentfiea Well Contractor I ! Dare
By signing thisform,l hereby avtifythalthewe l(s)was(were)cans/iudedin accordance with
7.Is this a repair to an existing well: ❑Yes or itiko 15ANCAC 02C.0100 orISANCAC 02C.0200 Well Construction San dards and thatacopy
If this is a repair frpout known well construction information and captain the nature ofthe ofthis recordhas beenprovided folk well owner-
repair under 021 remwiasection or on the back ofthisform 23.Site diagram or 8dttifiona1we11 detail.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well won info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovei'in Remarks Box).You may also attack additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 3 (fi:)
Formuttrple wells all depths ifdiif different(erample-3()a 200'and 2(a1100) Submit this GW-i within 30 days of well completion per the following:
10.Static water level below top of casing: /• 1 ( ) 24a.For All Wells: Original fowl to Division of Water Resources (DWR),
Ifwater keel is above casing use^+ Information Processing Unit;161E MSC,Raleigh,NC 27699-1617
11.Borehole diameter_ 9 (ul) 24b.For Injection Welln Copy to DWR,Underground Injection Control(RUC)
/� - • Program,1636 MSC,Raleigh,NC 27699-1636
12_Well construction method: /r A/Vah./ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Lc. rotary,cable,&ma push,`t`) countyenvieanmental health department ofthe county where installed
I
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells udnviver 100.i-I 1 GPD:Copy to DWR,CCPCUA
- 13a.-Yield(gpm) 4 Method of test: P 1fi 4 Permit Pro MSC,Raleigh,NC 27'99-1611
13b.Disinfectiontype: uJAJJof.i Amount: / G •
-
Form GW-1 North Carolina Department ofEnvimnmalai Quality-Division of WaterResmuces i Revised 6-6r2013