GW1--07728_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
a eft:r'e`/ 4cc/(er/ 5i-•an Pr;ce 14'VATERZONES ._ x;f
Well Contractor Nam FROM TO DESCRIPTION �j
y ft' f. ia?s 6 L..5
ft. ft. !
NC Well Contractor Certification Number
!anfan
/ G�1 h//t.s t' ielr //rt£// I'1 ,��C 40M TO DMER THINESS MATF'arar.le +/ ft. f. 6/( to ./1 gvC
�1 16'INNER'CASINGORTUBING'(geothermalclosed=loop) ;:
2.Well Construction-Permit#: /06 /3 i/ 9/ a . FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft. ' in.
i 3.Well Use(check well use): ft. 1n.
Water Supply Well: 1.7:SCREEN, '-
FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. iin.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) R• ft in. •
'� • ❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHO/D&AMOUNT
Non-Water Supply Well:` 0 it. oZ v ft �'i f enf l /- t e. red
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.❑Aquifer Recharge ❑Groundwater Remediation 19:SANDlGRAXEIsPAtK(ffapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. '
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer '20 DRILLING.LOG(tittach additional sheets if neccesga`ry)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soilltnck type grain size etc.)
9 et 4 © ft /!j ft 1 Re d t1o�
-4.Date Well(s)Completed:/� ` Well DM /0ft c9 0 ft. .,5y,.1/its A !! `j f J/!'w
Well Location: •° 2 0 ft' 14 I/ f• D iu e (j....vu.
VtclerICD- I`1IV ,o'Li- -Inves-6,04 / ft 7OfV eLU-e 6r
Facility/Owner Name LL '' Facility ID#(if applicable) [t ft. '
/3 t103 7n 0/>i 4.5 Rd f. it !I;,-.. �:?^`''
Physical Address,City,and Zip ft. ft. ." 7; ` ,"
T q„ ,
Oi�ecirien.64r l� a , -j' S1REMARK3 [��(' 2 23
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _;1,
(if well field,one lat/long is sufficient) 22.Certification:
3.5Qe673r7 N 8/. ,, Jc 13 W Lc -P-1.._
6.Is(are)the well(s): manent or OTemporary i y ea Well Contractdr Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.with
. 7.Is this a repair to an existing well: ❑Yes or '&O 15A NCAC 02C.0100 or 1 SA 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 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: 17a D (it.,
Submit this GW-1 within 30 du'ys of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2®100')
' r 24a. For All Wells: Original t form to Division Of Water Resources (DWR),
10.Static water level below top of casing: J (It) Information Processing Unit,1617I MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
il.Borehole diameter CO I/g (in.) Program,1636 MSC,Raleigh,NC 27699-1636
0 12.Well construction method: '` pr y 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 .
,f!) fr/' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) CVL �t Method of test: 77
13b.Disinfection type: d4 f /T Amount: 3 /2/1*s
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