GW1--05199_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information:
?IAA
19 •1�.. f-i-en-5(e? 14.WATER ZONES 1.__
tS'ellContracto Nam, I - FROM TO - —I-DESCRIPTION.
5 I f 6 it. II. /or It. I (5,in'
ft_ ft.
NC Well Contractor C�_tificttion Number
15_OUTER CASING(for multi-cased wells)OR LINER(if op licable)
-�. -1�1.5 e �5 ' 1 h \ / Mall TO DlA.\IE IER THICKNESS \iATER1AL
Well - r[ Ili i'l, I i'LG. _ r
companyName� V L�ft tj f� IL
i/y t� 0�'� (7 f�l/C— --
_ 16.INNER R CASING OR TUBING(geothermal closed-loop)
2.Well Construction.Permit#: 3S rr 9 q , FROM TO DIAMETER I TIICK"NESS I MATEMAL
List all applicable null rotstrrctian permits('i_e_UIC.Comte.State.Variance etc.) rt. rt. in.
3.Well Use(check well use): It it. in.
Water Supply Well: 17_SCREEN �"
t
FROM TO 1 DLQ4EFER SLOT SIZE THICKNESS 1 MATERIAL❑_ ericultnral ❑Municipal/Public ft_ rt. in.
❑Geothermal(Heating/Cooling Supply) 2csidential Water Supply(single) n_ ft_ in-
❑Industrial/Commercial ❑Residential Water Supply(shared) 18_GROUT
❑i ti_ation ❑Wells>100,000 GPD FROM TO SLtTERL1L PLACE\ME-'TIIE IIOD&AMOUNT
Non-Water Supply Well: fl It 3 ft_ th 14- c
❑j loriitorine ❑Recovery 3• ft_ 0 ft, l(-?J
Injection Well: 1�! (y ��
rt. rt.
DAquifer Recharge ❑Groundwater Remediation ^ nn�
19.SAND/GRAVEL PACK(If applicable),. .7!/1- - ------
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL / EMPLACEMtrxr31ETIOD
❑Aquifer Test ❑StormwalerDrainage i R_ .......--...._ft.- I
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) Di-racer 20_DRILLING LOG(attach additional sheets if necessary) 1
❑Geothermal(Heating/CooliugReturn) LlOther(explainunder421 Remarks) FROM fU DESCRIPTION((color.har`dnexs soitIrucktspe grain size etc.) i
rt5D
4_Date Wel•l(s)C•ompleted I Q r2O�.3 Well IDS 3 61 9,q 2. l O' CL fL /� f Gf_!) 4
Q ,e_br„y_�'_CJ �''1��C ;l/,6 rid t off'
Sa_\Yell Location O if-FL` \
�, ff ( JL!I l .I ti 1 Q�
Jft rt.
Facilit)dOsrtter urns Facility 11617(if applicable) ft •It. - •''a y_ n.,
Tl0rSr=S lOL. Ftl(Rk- Pticl` rcovk Ac- rt. n.. ,. v gym,s� 1
Physical Address;City:and Zip' I '1,S 7j'7 ft fL :AUG 1: `. 2 U I3 I
\I c \ . -0 4d,ci1 2I.REMARKS L
County Panel Identification No.(PIN) - - rti.S, ..t i,•',;a
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lot tong is sufficient) 22. ertification:
310' Ilt`ko , iY xT`5' . ;l_q- is y y- w _ 1yi
.r am 07 (o Zz3
6_Is(are)the well(s):f Permanent or- Di'emporary Signature of C td ie t ontntetor / Date
Sy signing this Awn,.I hereby certije that the uvll(s)was(were)constructed in accordance sink
7.Is this a repair to an existing well: ❑Yes or *No I Sd ATCAC 02C.0100 or IS_A A'CAC 02C.0200 Well Com:ruciion Standards and that a cope
jth&is a repair.Jill out krtowar well construction information and explain the naure of the ol.this record has been provided to the well otnmr_
repair under ii2I remarks section or on the hack of this form
•
23,_Site diagram or additional well details:
YOU may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ' (add'See Over'in Remarks Box).You may also attach additional pages if necessary_
tinned:. ,, /
24.SUBMITTAL INSTRUCTIONS
l •
9.Total well depth below hind surface: /�'o 5 ` ' ._For multiple wells list all depths if di(j-erenr(example-3 200•and?rattail)
(ft.) Submit this G\Y-I within 30 days of well completion per the following:
24a For All Wells: Original form to Division of Water Resources (D\YR),
10.Static water level below top of casing: 3(p (ft)
II-water letrl is atone casing.also
7nfomntioit Prvicessin Uutt 1617 MSC,Raleiglt NC_7699-161.7
• 24b:For Injection Wells:Copy ititD\VR,Underground Injection Control(IUC)
11.Borehole diameter_ (co (in_)
"" Program I630 MSC Raleigh,-NC 27699 1636
I2.\Yelt construction method: 141 R k0 T14 24 24c.For.Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,mwry,cable_direct push,etc.) county environmental health department of the county where installed_.____._
FOR WATER SUPPLY 3YELLS"ON'LY -•`
24d.For Water Wells producing over-100,000 GPD:Copy.to DWR.CCPCLIA-
13a.Yield(� m J -. j�‘ -- Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
by ) -Method of test: r C
13b.Disinfection type: •i /1p ��(-if_ Amount_ 1 0 a .
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- t=own GW-1 North Carolina Depanment of Environmental Quality-Division of water Resources Revised 6-6-2018