GW1--04231_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
tWWeAContr''ac(�� (altor//I��njj ,2aQ � ¢ filr./1
Information: L lCt'7) .23
!`ffr/,-my 4u - v g'� 14.WATER torus
Well ConnacrorName FROM TO DESCRIPTION
NC Well ComtactorCeriifiratioaNambes 15.OUrER CASING(formnldd-cased wells)ORLINER(if )
ie,e1A.
Lv-. /7 FROM ID DIAMETER ,THICKNESS ! MATERIAL
Company Name , p/.p - 16.MEE CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit It ' I 0 FROM TO DIAMETER. THICKNESSl.MATERIAL
List all applicableileJ(construction permits(ceWCCmmy,Stale,Voke.eta) 4'/ ft' 474, ft ii 'a' 5 C>-9Q Pi/-
3.Well Use(cheek well use): 4 / ft /pi_ft ii m ,(at-/le` /°l��
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOTS= THICKNESS MATERIAL
angricaltmal Municipal/Public S (o/ s 4/ ilL - k O 3 cm/
SS
°Geothermal(Healing/Cooling Supply) J9acsidential Water Supply(single) tti R. In.
olndustrial/Commercial °Residential Water Supply(shared) Is.mow
o lrrigation (Wells>100,000GPD FROM 10 MATERIAL EVIPLAC MENTMETHOD&AMOUNT
Non-Water Supply Wen: 0 IL .2/ Pole Pet PU?tJ✓
°Monitoring °Recovery a. ft. I J
Injection Well:
0. - it
°Aquifer Recharge °GroundwaterRemcdiation
19 SANDIGRAVEL PACK(if applicable)
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL E IFLAtEMENTMEIHOD
°Aquifer Test oStormwaterDrainage / B. 63 ft- ',Ai t,(.ff PFt_
°Experimental Technology - °Subsidence Control It. It.
oGeothermal(Closed Loop) °Tracer 20.DRILLING LOG(Math addlfioaat sheets ifneoeesarv) .
o Geoth (Heating ermal /CoolingReturn) OOthcr(explain under#21 Remarks) FROM TO DISCRU?TIOBI(color.tutdaess.m➢hotkt main ass,tie)
/ t 7 0. a o It .1&41 i'/
4.Date Well(s)Completed:Dip/off�!/23 Well BM/ `//`�3 87 a U ' (p e6,14.Le_, �u)L/L, Ac'vr!/
5a.Well Location: t2 rft- 7 O t. � d t
104,,Si4,ii ayrla 141 ,;c'e,14.1 ar ft.-
Fmlily/OwmrrName FaciityIDS(if applicable) H' ft.•
Al A/C / a i/ ti � •' �C _ f r v�
V ! ft. ft. is °a%t.�4.r'R + -
Physical Li
/uoiG - q4.0, �4 21.REMARKS
/l 1 J��l e /v Jl l 7 i `
County Paced!Identification No_(PIN) • ../r_,--.: ,,i t;r:
r-ie(::J:'l 'y
5b.Latitude and longitude in degrefis/minutes/seconds or decimal degrees: tnr� C :,.'"p'�' � r/ �/
(if well field.one lat/long is sufficient) 22.Certification: 41 (,v &J , 4n(,i,f_afLt oL9/i1-
XD Ill J-2 r. N �/ a 3g r 33'` - w ritir), TO
6.Is(are)thewen(s): 3ermenent or °Temporary Sigaatune of Certified Well Contractor i Date
By signirigthisfora,1 hereby cutifythat thewell(s)was(were)constructed in accordance with
7.15 this a repair to an existing well: °Yes or -AINo ISA NCAC 02C.0100 orIIANCAC 02C.0200 Wei Construction Standards and that a copy
If this is a repair,fill oat known well construction information and explain the nature ofthe of this record hos helm pmvided to the well owner-
repair under ON neemad=section oron the back of this form.
23.Site diagram or additional well details:
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'inRrmmarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4-g ( ) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list ail depths ifdiffennt(exrmnple-3Q200'and 2(a)l00)
10.Static water level below top of casing: 30 (.) 2ta. For All Wells: Original form to Division of Water Resources (DWR),
Ifwarerlevel is above casing use^+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 9 On) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
-
Progtam,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A'fa,41 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(u auger,mazy,mid;&ea past,ctc) county environmental health depattmetttofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to
Permit Program,1611 MSC,Raleigh,NC 27699-1611 DWR,CCPCUA
" 13a.Yield(gym) 40 3 Method of test p
13h Disinfection type: l.(l,/, ,Sap
Amount I t3'U
Farm GW-1 North Carolina Department ofEnwonmental Quality Quality-DivisionofWatcrResomccs Revised 6-6-2018
I