GW1--07729_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well-Contractor Information: f
• TeFFrel// %cccA'ee / Oct'a-n
.
Well Contractor Nalne FROM TO DESCRIPTION
ft, ft.
NC Well Contractor Certification Number
15:`.OUTER CA SING(ffor Multi-inset wwells)OR-IINER(if ea' able)
FROM :may / /y(a1iSWei/ 27c LfIPY j2 c TO
DIAMETER
THICKNESS MATERIAL
Company Name"'" FRL ®at f4n
05 p /c.
2.Well Construction-Permit#: ��(� 7 16ANNER:CASING:OR:TUBING'.(00thei•inal dosidzloop) 111 ' !/
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perririts(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
4 3.Well Use(cheek well use): ft. .ft. in.
4.
Water Supply Well:
❑A CUlturalFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Z OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)PPY( g )
❑IadustriaUCommercial f� i 1A'
❑Residental Water Supply(shared)
<ation [Wells>100,000GPD ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 0 " 427- /0
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Bechar ft ft.q ge ❑Groundwater Remediation
..19.:SAND/GRAVEL`;PACK(if•apPlicable) : - '❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
• ❑Experimental Technology ❑Subsidence Control ft. ft. i,
❑Geothermal(Closed Loop) ❑Tracer 20;DRILLING LOG(attach additional sheets.if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,pram size etc.)
I J (9 ft, C2 O ft. Red eCa t
4.Date Well(s)Completed: 1/ 'Js".2.{rell IDit a 0 fr. tit 0 ft PPli c/:.=-v-e f/
e d KDc4
5a.Well Location: ,,t / 0 ft. I G �/,i( is' .f ,_. /i'
l'SIal is cAd /C''l��f° �vp'� due _Faity/QwnerName Facility1D# ife liable ft• ft. _
'7561 Ere ySOn He/�4is Vic ft. ft. n%.
- Physical Address,City,and Zip f6 ft. n=r : 2 L'23
M ecc Alen b&ir )I '5. 37J 03 2I ItEMAR&Ss'::
'4 ,.... .• .y .ter.R
County Pastel Identification No.(PIN) I>a:, •L,3
513.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
35+ 0 g P O % N feD/'� 3 '7
6.Is(are)the well(s): t manent or ❑Temporary of Ce ' ed Well Connector Date
By signing this form,I hereby certi.0 that the well(s)was(were)constructed in accordance.tvith
7.Is this a repair to an existing well: ❑Yes or MNo 15A 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~yell owner.
, repair under#21 remarks section or on the back ofthis form. 1
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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GWW1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 0 0
Submit this GW-1 within 30 dais
For multiple wells list all depths ifdderent(example-3t200'and 2Q100� ) ys of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
r Ifwater level is above casing,use '+" Q (fw) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy Ito.DWR,Underground Injection Control(IUC)
11.Borehole diameter: /u (in,)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /�f'j1K-I''V
(i.e auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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) Method of test: f!1/�
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Mt
t ! Amount: 3 p•'/17L-s-
1