GW1--05827_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information: i
-_
eh.,111, . • .�i1�le_k. 14.WATER ZONES , I
Well Connar or Name FROM TO -- 1 DESCRIPTto\
ik I L L0 I!.. It$ fr. Al gR„,
NC Well Contractor CrtifrcationNumber �15 rl_ �,�5 R. l c(Y\
15.OUTER CASING(for multi-cased inells)OR LLNERI(if ap limbic)
1 `� FROM TO DI,�x1Er€R • THICKNESS xt AT(ERIAL
e_n.5 f 2cl S i1\RAN t t t \1, k in C. . I 1 1 v
Company Name 1 I-r IL '� fL 6�I i tn- s Dr� Q
16.INNER CASING OR TUBING(geothermal closed-►oop) -
2.Well Construction.Permit : 2 q ,tj 3 FROM TO DIAMETER TntCI.'NESS I MA rrEtu.v.
List all applicable nnll construction permits(IA LrUC.County;State.Variance.etc) iL it. in.
3.'Well Use(check well use): IL IL in
Water Supply Welk 17.SCREEN �'fl
a-lericuliural ❑tVtunici p`�UPublic I'RO\7 TO ma)iErER SLOT SIZE THICKNESS �ATERL%
fL IL in.
0 Geothermal(Heating/Cooling Supply) ticsidential Water Supply(single) D_ It. in.
❑Industrial/Commercial ['Residential Water Supply(shared) 18 GROUT
❑Imgation ❑Wells>100,000 GPD FROM TO 3MATERIA
Non-Water Supply Well: ^ IL , IL i IPLLCIp
UMonito \IEIIfOD S,��IorrT I
nn. — YlRccovery (J IL iL ` ,
Injection Well: �J �� ov‘Ite \Wr(
IL IL
❑Aqutfcr Recharge ❑Groundwater Remediationj (
❑Aquifer Storage and Recovery [Salinity Barrier 19_SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLAC_E-\ML\TMIETIIOD
❑Aquifer Test ❑Stormwater Drainage rL --IC It 1
❑Experimental Technology ❑Subsidence Control R. R.
O-Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothennal(Heating/Cooling Realm) "['Other(explain under 421 Remarks) FROM TO DESCRIPTION(color;euirraess sontmck type in size etc.) t
( ,0,."L_ ._-a0 -, ri._: O't' 9011 : . - !{
4.Date,Weli(s)Completed:055 f(S ,A-3.WelllD#-3 C)?)5 3J-. . k?„0 n_ Lb, rt-. lm ''t fi4 1,( • .._..
-
-5,a 1%cl)Locatio_n:,••- _, _:... --_• .- -•- . ._ 07 ft r (1 �r� R
� q i ( 2�Tu•r 6c��
kiitI ►•rrWc ZJsft ft .
2 t� v1LJc�-�d`5 �b ,vZ�5• .. .�t•t.�_vY�•1 ���-2.>. , .. ._' j
F•acility/OwnerNaim I1< AA
Facility(01/(if applicable) ft.' r'ft. 1
(n� n fi, II.: _
I+Vg 0'Ol 11 a n► A V laQ SO n t A C 7.'1 S 3'1 IL a. � P--•°r- s_-':1 f "� 1
1'lryicatAddt>=$s, ity,andZip . l4 �.�L.i V A�
21.REi/ARKS QY p, ao i poi ,►
3SEP i 20,—.)
Gorwty ' .... Panel Identification Nn.(PIN) _ • i ,;� /•
Sh.Latitude and longitude in degrees/minntoslseconds or decimal degrees: 1,� ;y 'i^:1: r 53' 'e`3!�' i
(ifwell.field..oneIat/long is sufficient) : • 22. `+:`�C�La
e tificarion: '
31c, ).-'q 000 ti 'ZS, 2,4( 2.00 w
6.ls(are)the well(s):`y�Permanent or la emporan I. S L lure ofC- ified 1 tractor •s _ Date
ttr signing this form.I hereby cern/r•t in:the well(s)was(were)constructed in accordance nitlr
7.is this a repair to an existing well: ❑Yes or %Iiisio 154 iVC.IC 02C.0100 or 15_I A'C_-IC 02C.0200 Well Construction Standards and that a copy
!Phis is a repair,fill out known well construction information and explain the nature of the ol'this record has hell provided to the urn ornrer_
repair under 421 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 _-
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction;only 1 GW-l is needed. Indicate TOTAL NUMBER of wells - (add'See Over'in Remarks Box).You may also auaclti additional pages if necessary_
dolled: ' 1 24.SUBMITTAL INSTRUCTIONS .
? 7
9.Total well depth below land surface: .5 - (ft.)
Foi-multiple wells list all depths if different(example-3(_00'mid,olR�) Submit this GW-I,within 30 days 4 f well eomple>Ygp per the following:
10.Static water Ievei below.topof casing: - O 24a. For All Wells: Original form to Division of Water'Resources (DWR), •
If water level is above casing use"?-'
(fL) Tnfo0masj9n Processing Unit,1617 MSC,Raleigh,NC 27699-161.7
11.Borehole diameter: 'p (in.) , 24b.For Injection Wells:•Copy.to'.DWR,-Underground injection Control(IUC)
-- - Program.1636 MSC,Raleigh,NC 2 7699-1 63 6 ' .
12_Well construction method: 'Al Q. ROT-A--RA - d - - r
(i.e auger,rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:.Copy to the-
ry cable direct push etc) county environmental health department of the county where installed
FOR WATER SUP1'Lli`1i'ELLS ONLY: � .'. - r
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA -
�. Permit Program,1611 MSC,Raleigh.NC 27699-1611 -,- "
13a.Yield(gpm) -' [_Method of test: e i q - .
I3h_Disinfection type: G14)Y`t 1 Amount: -6 0 in
Form(lW-1 North Carolina Deparuncm of-Environmental Quality-Division of Water Resources Revised 6-6-2015