GW1--07726_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j •
1.Well Contractor Information: 1
�ClC f rey —fie . )t!f,J8f,ee ri /i�Jf t/C e 14:WATER ZONES. ;- 1 '
FROM TO DESCRIPTION
Well Contractor Na ft R eaol 710
�1J o •
ft. ft
NC Well Contractor Certification Number �,15 OUTER CASING:(for inapt I'sediiells)OR LINER('dap"livable)
/ / FROM TO DIAMETER THICKNESS MATERIAL
�" ZC�/ /�S �ifJ�L� �i�/C-(l ��C 1 / ft. / ft. 6IY5 tn. , 423' i'"triC
Company Name 7,
p !3, '16%INNER:CASING OR T[IBING?(geothern el•dosed=loop) ;:_
2.Well Construction Permit#: f 00 /3 `_3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(le.UIC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fa ft in
Water Supply Well: •17:SCREEN• .. :
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. ;in.
' oGeothetmal(Heating/Cooling Supply) fOreSdential Water Supply(single) ft. ft. "in, •
❑lndustrialCommercial ❑Residential Water Supply(shared)
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. it. p
❑Monitoring ❑Recovery ft. ft. e�l 14A�1/ D(.4./ c'i
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK(if applicable) ,
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control ft. ft. i,
❑Geothermal(Closed Loop) OTracer =20 DRILL•ING'I:OG'(attach additional sheets,if necessary) -,''
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soIDrocktype,aratn size ern)
/ 0ft AO ' Re8Clu/
. 4.Date Well(s)Completed: /0"401 "2.3Well ID# 0 it li itZY `o G �.
a.Well Location: :,� Ct)�� J./ n• ,�Z-Gc to to 1L•a✓►'I..l '
l vtrAes- ' 1 yea ern -( ter-(-lnra-Is ft. ft.
Facility/Owner Name J Facility ID#(if applicable) ft it.
15 33 q 7h a S d H. ft
Physical Address,City,and Zip ft. ft. DE r el t
mEc� Pr) bur - 2 7 2 J�' 0 .21 nEM,uKs•. i,4::: Zo23
County Parcel Identification No.(PIN Di A'rs.c— '. '' -'"i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one mat/long is sufficient) 22.Certification:
350 fi e r7\5 8' N g / S O/O S t W �Q ..�d2—�Z3
6.Is(are)the well(s): ermanent or ❑TemporaryRI::) ed Well Contractor Date
I;
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or •erlYo 1SA NCAC 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 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 1IW-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
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9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2®100)
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"+"
�� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6 �$S (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
�[,, Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: g0%t.t 5/ 24c.For Water Supply and Opfen-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: i
24d.For Water Wells producing over 100,000 GPD:Copyto DWR,CCPCUA
" Permit Program,1611 MSC,Raleigh,NC 27699-1611 "..'
13a.Yield(gpm) 3 D Method of test /7/r' ..:'hey,: •,'
h+r.
1, / f v 54!
13b.Disinfection type:irf 7/'T Amount•" n f S