GW1--05157_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t r C Sa„Cl af-t o'^ 14.WATER ZONES;:..• ,:. .,' , .
Well Contractor Name FROM TO DESCRIPTION
ft. ft
ft
X70 ? .
ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells),OR LINER(if applicable)
361 Job;"— 1 Ii!L (q bi`1/t FROM TO DIAMETER THICKNESS I MATERIAL
N .:� 0 ft. / ft 7%t in- . g 11 ,PG
Company Name V G
-� 2 16.INNER CASING OR TUBING(geothermal closed-loop)', '
2.Well Construction Permit#: 3 33 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®I Agricultural QM r'cipal/Public ft ft. 7,r in.
(Geothermal(Heating/Cooling Supply) esidential Water Supply �v �b� z i Z S��F yo Pie
® � � g PP Y) � � PP Y ft ft in.
*IlndustriallCommercial DResidential Water Supply(shared)
'Irrigation FROM TO MATERIAL EMPLACEMENT ME D&AMOUNT
Non-Water Supply Well: D ft. Zd r ft / q! „,1 6 T'dfi tr d .c Fay.
V t'
Ai Monitoring Recovery ft , ft �[ / '
Injection Well: 7 � �
ft. ft.
MI Aquifer Recharge QGroundwater Remediation
19lSAND/GRAVEL PACK(if applicable)
Ii Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®I Aquifer Test QStormwater Drainage ft. ft.
*Experimental Technology 0Subsidence Control ft. ft.
*Geothermal(Closed Loop) llTracer 20.DRILLINGLOG.(attach additional sheets if necessary) _ '' .
. ®I Geothermal(Heating/Cooling Return) l Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Hardness soil/rock type grain size etc.)
0 ft2.) ft- 5'.0 yOt'lc.,/ r6r .
4.Date Well(s)Completed: 013/V/23 Well ID# at. ft L-c? ft. S(c(.e L4,, 54 n 1
5a.Well Location: Ltd
ft. 60 ft. 3;I C J4St
r�
a ;51-; z Jv�•,os 60 ft x° ft dry/ ci (:
Facility/Owner Name Facility ID#(if applicable) i) ft. too R' L"-i c Sttn.// 1,0A! G IrtA
I q/ Royur D / AA1 Fo4 / 2 s 3 6 V ft. ft
Physical Address,City,and Zip j ft ft.
��1� o! d�6 Q L 2I REMARKS: h'^.+ , '� --v t i,f,.r E.,,�
�L�@,jG i1 1.. r a -
ta N.... �..1i 1 '.1,�,
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: AUG 1 L_ 2f123
(if well field,one lat/long is sufficient) h 22.Certification:
N ?9 / 95 W �<<a - v,�� � ��� z
6.Is are the wells Permanent or j Tem ora Si ature of Certified Well Contractor Date
Is(are) () P ry
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or la o with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under il21 remarks section or on 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 0 © (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: Cp (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: PO
4. r- above, also submit one copy of this form within 30 days of completion of well
constniction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .._20 Method of test: A.C /.,/4 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: '/T Il/ Amount: 3 04 completion of well construction to the county health department of the county