GW1--07637_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1 Wel Contractor Information: 1
� J �U l I%S . 14 WATER ZONES.:.: ::--:
Well Contractor Name FROM TO DESCRIPTION
0-CZ12.0ft., ft. 10-CZ CI ,60 ft., ft. i
NC Well Contractor 'ficationNumber
(��(� g f( c ( �� II ` �(� .15.:OUTER CASING'(formulti-cased:WelISI.OR LINER(Rap'Ratite)':,::•-.`:-::-:-:::: .
J� l fl (l (` J VueU L l iIUVv, FROM
TERIAL
"44 ft. TCI/ ft. 0 /I jt O DIAMETER in. I7.0 1 THICKNESSh VC
Company Name J 1 P� zY
.� r-1 (-4�� ,16:INNER.CASING:OR`-TUBING(getithe tiaTdosed=loop) .
2.Well Construction Permit#: `` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ' in.
4 3.Well Use(check well use): ft, ft. in.
17.SCREEN _ ,t-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ untcipal/Public ( . I ra.
OGeothermal(Heating/Cooling Supply) Residentialft„ ft Water Supply(single) ft. ft. I in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROITi
❑lrrigation ❑Wells>100,000 GPD FRO To ' MATERIAL EMPLACEMENT METHOD& MINT
Non-Water Supply Well: ft. �(r
❑Monitoring ❑Recovery ft. (.F` ft. n l� pPi
Injection Well:
ft. ft. •
❑Aquifer Recharge ❑Groundwater Remediation '
":19 SAND/GRAVEL-PACK'(if applicable):-:. . -.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20 DRILLING LOG'(attach udditiotialslieets-ifnecessary) ._ ...
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) CO ft. t4e-gti Cs tt•-V
4.Date Well(s)Completed:I0-1q-C15 Well ID# /0 ft. 20 ft. b 1
5a.Well Location: :,t_ 'Xj rt. BO ft' `,itl s4orpe,
` I(
(011114 Q-U 1 eRin1f(,.. riv i', 1 et) f` -,Cd 11r.es ne /g'A.r.i Ac
Facility/Owner Na e Facility ID#(if applicable) R' R•
(9 1 LI Hitrin I [ RC). . Cf)60}-1e k6V6
Pltysi I Address,City,and Zip ft. ft. °;^' ._:,i; l ';::.'1 1
0 1 c-1 e it lcA / Or/ 2]:RE1VIi►RKS:. n� .: + :.�1 J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i n.. .a., c . 'i_i �"
v r �1 J i
(if well field,one lat/long is sufficient) � 9 22.Certification: / /�
360 2t 1 D - {'S N S% 321�{ W iO—I 1- 3
6.Is(are)the well(s): ➢9Permanent or ❑Temporary Signature of Certified Well Contractor Date
'' \\ By signing this form,Thereby certify Mat the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or L9No 15A NCAC 02C.0100 or ISA 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 remark 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
constriction,onli 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box),You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 CO l (ft)
For multiple wells list all depths if different(example-3i'200'and 2( 100') Submit this GW-1 within 30 days of well completion per the following:
��/ (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
h 10.Static water level below top of casing: Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
Ifwater level is above casing.use"I-I"
11.Borehole diameter: lQ t I 4 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well str Hon method: e\--VC-- 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.au! r,rotary,c•.le,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
13a.Yield(gpm) 50 Method of test: ikl`r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: I C Pc Amount: \