GW1--07101_Well Construction - GW1_20231103

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WELL CONSTRUCTION RECORD G�-1
For Internal Use Only:
1.Well Contractor Informatiotq
Qt•d VJ t d4�I �y 1
11
(1 )��
Well Contractor Name 14.WATER ZONES I I •
FROM TO I DESCRIPTION
3ag76 ft. thI1
NC WeII'Contractor Certification Number ft. ft.
` �f IS.OUTER CASING(for Multi-eased wells)OR LINER(if an licable)
C ..5"G Cg,e,./e brl It B Ae FROM TO DIAMETER THICKNESS MATERIAL
Company Name R. ft. I M. I
2,Well Construction Permit#: pp �j �p P 16.INNER CASING OR TUBING(geothermal closed-loop)
p A CAUL e L i Sine FROM TO ' DIAMETER THICKNESS MATERIAL
List ail applicabletie!l construction a nits i.e.UIC.Con*State,Variance,eta) ft.
ft. in.
3.Well Use(checkweB use): Per-*r//,°�5 a-'if
ft, ft. o In.
Water Supply Well:
PP Y 17.SCREEN
❑AgCICUltllral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipsil/Public ft. ft. in.
°Geothetma((Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Conunercial n' n t"
❑Residential Water Supply(shared)
1K GROUT •
❑Irrigation
❑Wells>100,000 GPD FROM TO • MATERIAL'' EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: ft. ft. 11
❑Monitoring ❑Recovery •
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Injection Well: . ft. ft.
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❑Aquifer Recharge FI130<ridwater Remediation fL ft.
• ❑Aquifer Storage and Recovery ❑Salinity Barrier •
19.SAND/GRAVEL PACK(if applicable) •
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test ❑Stormwater Drainage . . rt. • ft, 1 '
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❑Experimental Technology ❑Subsidence Control • ft. ft.
OGeothermal(Closed Loop) ❑Tracer ' 20.DRILLING LOG(attach additional sheets if necessary) •
❑Geothermal(Heating/Cooling Return) Cher(explain under#21 Remarks) FROM TO DFSCRirrioNZcoIar,hardness soli/rock type,grain size.etc.)
' fir* - /% ft. ��r EL
4.Date Well(s)Completed:/0 4-13 Well ID# 7 2. ft. ft. „rid"-
�3¢ ear .S' ���a�'�6.g�d'
® �xp •�1�stcaregdtgo�
5a.Well Location: ry, 1
/3& OtveJ our C,ers-�opttr Rwk S.Ye ./ycey l�2.y6 t'yin H f Li. -
Facility/Ors net Name f FacilityL.
IDO ft.applicable) • ft. 1 f' - _
®�,] t'� eUare /3/✓ Y ft. ft. .I ,,i._ d zuY if-a
Physical Address,City,and Zip ft. - ft. ��� e• Z�fl.� -
O, -510 iAP 4/3 91/30if781® g21.REMARKS tn;�l; :,
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County Parcel Identification No.(PIN) d t>r � a t er�fv e. a''- e rr• Sctct ; .0 t,••.: ei:45 •
O oc+
Six Latitude and longitude in degrees/minutes/seconds or decimal degrees: Yee:e't �6 eit'ch d�-t`c.for e e..vs!r eic f iw ei c ot,p is
(if well field,one tat/long is sufficient) 1,22.Certification:
/Valli 116 49. N '7"7,. 3 1 I 00 w 4,/,ea...:7 4,,,s....,,A . /,,,st___23
6.Is(are)the well(s): 'ID1�errnanent or ❑Temporary Signature of Certified Well Contractor Date
7.Is this:a repair to an existing Well: ❑Yes or Bysigning iwisfarm,Thereby remit.That the iell(s)was(were)eonst•«cued in accordance with
gttl • ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repuirdill out known url!construction information and explain the nature of the ofthis record lies been provided to the 110 owner.
repair under#21 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells '(add'See Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: i.
O / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ' (ft.)
For multiple wells list all depths ifd�erenr(example-3 rc 200'and 2@I00� Submit this GW-I within 30 days of well completion per the following:
®e 10.Static water level below top of casing: „ , •24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617R MSC,Raleigh,NC 27699-I617
II.Borehole diameter: 6 (lit.) 24b.For Infection Wells:Copy to DWR,Underground injection Control(WC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: go 0-�0 e 24e.For Water Supply and Openi-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 producloglover 100,000 GPD:Copy to DWR,CCPCUA
13e.Yield Program,1611 MSC,Raleigh,+NC 27699-1611 .
(gpm) Method of test:
13b.Disinfection type: Amount:,
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Form OW-1 ' North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018