GW1--06873_Well Construction - GW1_20231030

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
vaniIc� M*10,S(� - - ' -• - - .. .
=14.WATER-ZONES i -
Well Contractor Name ,,//�� FROM TO, DESCRIPTION
—fi-t C ft. SCa© ft 4D��
ft. ft. ;
NC Well Contractor Certification Number'n j/J Q 15:OUTER CASING(for midtt-cased wells)OR LINER(if up'licable)- '
V ' e_ �—/ I Yl C - FROM ft. TO
ft. DIAMETER THICKNESS MATERIAL
hi.
Company Name n 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: L t�D as 3_Q -1 1 FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction penults(i.e.UIC,County,State,Variance,elc.) 0 ft. i 1 ft. �in. aZl f c
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
iil'Agricultural 0Municipal/Public ft. ft. . le.
•Geothermal(Heating/Cooling Supply) f°Residen i. Water Supply(single) ft. ft. in.
*uIndustriallCommercial 2,'=.idential Water Supply(shared) ig:GRou'r . - - • . . • '
' :)Irrigation FROM TO MATERIAL R�4IP IM I.A�EIE OD&AMOUNT
Non-Water Supply Well: 0 ft. 2Oft. 10„ic - k ((/�j/f�J
vi,Monitoring Recovery ft. ft. 01119
Injection Well: ft. ft.
all Aquifer Recharge I°GroundwaterRemediation
19:SAND/GRA L-PACK(if applicable) " -.... '
It!Aquifer Storage and Recovery (°Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test °.- Stormwater Drainage ft. ft. i
M Experimental Technology °Subsidence Control ft. ft.
it Geothermal(Closed Loop) Tracer 20:DRILLING OG(attach additional sheets if necessary) .
111
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
0 ft- I 1 ft. act grove -h-trdz .
4.Date Well(s)Completed:q'"a7'a 3 Well DM 12 1 ft. Lp Deft. / ._�ti� 4'R
5a.Well Location: ft U 1� 1
3+--eOC .y±1 h� ti--l- ft ft ` �'^°(":1-2..:" .:.;'a J
Facility/Owner Name Facility lD#(if applicable) ft tt U C T 0 ?n,3
I V 1 2 0 Ti-et;) n� p ft. rt 3
nine S 1 RG�SGII'rt �iirt�[ s Inr;,;;r..^:�, ,,,.___, .
Physical Address,City,and Zip N� f� �+���j$^�Og ft. ft. ; CA-VC:.:"!,Oil
�rta_irk tt I valet ea e5"YIP-b J- S"g'" 06,3 21:REMARKR_'._:- `•:•j-, - _ .. -
County Parcel IdentificationNo.(PIN) f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees;
(if well field,one lat/long is sufficient) 22.Ce • tion
gs ° iui ) 2.77(o33S'x Rae'5) `a3,r599355 " W
9 a7-23
6.Is(are)the well(s)�,•ermanent or °Temporary tura of eettifi Well con nor Date
By signing this fo ,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or with I5ANCAC 02 .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 as been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use th 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 dot Is. You may also attach additional pages if necessary_
drilled: S1TRM17'TAT. C CTRUC-r)'t�NC
9.Total well depth below land surface: l.C2 05 (fL) 24a. For All W Ills: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,/jerent(example-3@200'and 2@l00') construction to 1 following: 1
10.Static water level below top of casing: 0 O() (ft.) Divisi of Water Resources,Information Processing Unit,
Ifwater level is above casing use"k" 16 7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO - a (in.) 24b.For In ecti n Wells: In addition to sending the fonts to the address in 24a
12.Well construction method: I -0 above,also sub it one copy of this;form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to th following: I
Division of ater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 6 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m
(gp ) 3 Method of test:1101). 0",/►1tq thQ,e 24e.For V ter u 1 &Injection Wells: In addition to sending the form to
the address(es) Bove, also submit one copy of this form within 30 days of
13b.Disinfection type:041)O yi` Q-- Amount: [p 4—GlioS completion of w ll construction to the county health department of the county
where construct .
Form GW-t ---