GW1--06313_Well Construction - GW1_20230926

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Yak . . k 7( leA\ 14.WATER ZONES
WellContrac rNamc FROM TO DESCRIPTION
?1.15 fl. Sift. l; -F"�1
`}I It. it
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap,licahlc)
\ , p FROM TO DI}1rE R THICKNESS MA RIAL
�}�VLS I�y s W 2S l r,lt1 \Inc... �-r ft q n 4� in Oki �C�
Company Name
l V ��Ilt 4s"d' •Vl�e-a
•�,q (� 16.111ER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �J-I -11 I S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,Counts;State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): rt. ft. In.
Water Supply Well:
17.SCREEN rl Pt
FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in.
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❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © It. 3 ft. MTkcwt. TpuLvi,uped
❑Monitoring ❑Recovery 3 ft. a© tr. ��p �t tY1� dZ
injection Well:
�l� `ir
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) /J 14
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) •
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,maw size,etc.)
0- H. - R.• 9'j ''epA ()1 I p
4.Date Well(s)Completed:- ' a0 Well iD# y-`'t.11�-5� lk 0 ft. 0 ft• ft Q 0.�1 csa 1ck.-(�.Q_--
\,k a �Il'ek - ,tf-.
Sa.Well Location: --- .. .- ._-.. - - �� .fr. 9 p ft ��C ` r `.
t Ci -
i t - o R. 2,S S rt. ci Ct-
O z= YVl l l�-►I �l re1 g d uYL e�
Facility/Owner Name Facility 1Dit(if applicable)
ft... R.
1 7 1 A 1' ,--otn A(- �Z S 3 7- .ft. - ._ ft-
Physical Address City,and Zip ) H- H- • ' i.../- o I. r-
..
Q`1_- /+ - 0595
0 I O 21.REMARKS /�t "
County ©. Parcel identification No.(PIN) S F P !A6 70?3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1t 1; ,i,.)::..,1 s'i t•3 ,•',;.,:j 12 n.
(if well field,one lat/long is sufficient) - 22 ertitication•- - DiA, :```�Lr
`'‘, l\ N qS' , A ®I(k. W
\ire >
oq ,26,i), 3
6.Is(are)the well(s):rPermanent or ❑Temporary S gnature of . rtifie \\ r Contra Date
-' fly signing this form.I/•reUv certn rat the well(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 12f.No I SA iVCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 reniarls-section-or on the back of this forin.- -- -
23.Site diagram or additional well details:
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8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Youmay use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: J 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: S Sl (ft) Submit this GW-1 within 30 da ys of well corn letion er.the following:
For multiple wells list all depths if different(example-3(0.200'and?it 100') Y P P
a U 24a. For All Wells: Original.form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
///water level is above casing,use"+11'• .. -
11.Borehole diameter:- b (in.) 24b.For Injection Wells:Copy to;DWR,Underground Injection Control_ow)
p �/ Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: l 1 O - 7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 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: t�
13b.Disinfection typeclD V111a(` 2�Amount ®Z 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018