GW1--04985_Well Construction - GW1_20230807

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1:Well Contractor Information: i
J1) AJwr &r14-Yl(S<r!h .'I4.WATERZONES I -
FROM TO DESCRIPTION
Well Contractor Name
u5r 3/; %i ft. //rt. fe r •
NC W 0 Contractor Certification Number � ft. IN f` `''� a�j�� -
�, ��� ��� �� � / � '�i'I t.15.0UTER CASING(for e71s).OR•LllVER(I[ap-lteable}. ..
!'/� �•.(/, l r FROM TO DIAMETER TTRrICKNESS MATERIAL
Company Name �/Z//0. 1 f')d it. t°. 7/.I 4(a Yvz/
(J/1 /G ,I�1 �f'1 �7'7 16.INNER CASING OR T(1B G(geothermal oseddoap)
2.Well Construction Permits: r k! J026,2 3 -/(I() / J 7 FROM , TO DIAMETER THICKNESS MATERIAL
tut all applicable well a m:rarllan permits(i.e.UIC Canary.State.Variance.eta) it• ft. in.
3.Well Use(check well use): tr. ft. ia.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑A cultural ❑Mimici a1/Public tt tr. n In. l
£]Geothermal(Heating/Cooling Supply) esidential Waters 1 (single) ��� 2 !/�'
� g/ g PP Y) �, � Supply (t ' ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ' '
❑irrigation DWells>10t1,000OPD FEOM Thfo - - 'TERM '-aatrvAcnMENra-Ernoo&en MINT-—
Non-Water Supply Well: f. Q ft. ( d,04' :OD/ 5
❑Monitoring ❑Recovery (rr !L CJ re. •
Injection Well:
ft. ft.
❑Aquifer Recharge UGroundwater Remediation
•19.SAND/GRAVEL PACK(if applicable)
Cl Aquifer Storage and Recovery - ❑Salinity Barrier - FROM "MATERIAL EMPLACEMENT arErRoD
❑Aquifer Test ❑StomlwaterDrainage PO ft L0 ft J lf//�j�ie�/rJ4 cedz.ea.�
❑Experimental Technology._•' ' ❑Subsidence Control ft. ft.f
OGeothemlal(Closed,Loop) : . ['Tracer -20.DRILLING LOG(attach additional:beets ifneceusery)_-
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Geotbl§irial FRObr TO • DESCRLITIONJcoior,bantam,sotVreck type,grain tiny etc.)Ci (Heat ng/Cooling Return)i;;t;❑Otlier.(explain under 1 Remarks) ft. ft.
4.Date Well(s)Completed: ✓ Well ID# .h
5a-. 'Well.Location: / ._._ _ .- _ ft R
. Famlity/owner Name FaciilelyIDO(ifapplicable) _ kJ._7 J L-.,, V ?_.
-3113 balmlito_gei NC. ft. ft.• AUG 0 7 2023
P teal Address. icy,and Zip
r o, b1 )/ 21.REMARKS 1FIiC"v+7
County Parcel identification No.(P1N) fl+s'Sr•yzrt;,,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well fiel one latf5R issufficient) Certilleati C •
. ;,4://::ezLz/
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6.Is(are)the wetl(s) ermanent or ❑Temporary um of car
signing thlsform.l hereby Bert that the well(s)nor(were)construe:d in accordaneewith
7.Is this a repair to an existing well: OYes or ho 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy .
Phis Is a Mall:fill out bestirswell construction information and explain the nature alike ofthit record has been provided to the wen onrrer ..-
repair to:der 021 remark section or on the back of this form 23.Site diagram or additional well details:
8.For GeoprobelfPT or Closed-Loop Geothermal Wells 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'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: •2( Ov (ft') Submit this GW-1 within 30 days of well completion per the following: .
For multiple wells list all depths if dierent(example-3@2 and 2Qa 100) t• , ..
( '' 24a. For All'Wells: Original form to Division of Water Resources (AWR),
10.Static water level below top o[casing: b (I>:) Formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617 - i. -
IfxvterkvelIs above casing use"+' - ,
17.13orebole diavrefer: y •��/ (Ln.) 246.For Infection Welis:Copy to DWR,Underground Injection Control(IUC)
rill
. ,/ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction-method: --PYI Ci ro 111 i fL/ 24c.For Water Suppply and Open-Loop Geothermal Return Wells:.Copyto the
lie.auger,rotary,table;direct push,etc.) / county environmental health department of the county where installed - -
FOR WATER SUPPLY-WELT S ONLY: 24d.Far Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
c/nJ Permit Program,161 1 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) D Method of test:rtJ�.•
I3b.Disinfection type: � Amount: �f O C7
/ f
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Form GW-I North Carolina Department ofEnvironmentalQuality-Division of Water Resources h `; ' Revised 6-6-2018 \-