GW1--07860_Well Construction - GW1_20231205

vv. Ll.LullD11tUL.lYU1V.i'U CUKU(iliW-11 For Internal Use Only: I
1.Well Contractor
IInform Lion: .
V.e ii 1 V 1 r l 1 1 lC. ( 1o.4 1 rN .S G C. A f. -14:"WATER ZONES.:; .':°
Well ConuactorNtrme FROM TO DESCRIPTION
. 95 f. ft.
2 c 4 r. - ft. ft.
NC Well Contractor Certification Number` ♦ ':15::OUTERCASING'(foi multi-cased;wells);OR LINER(if up"liable)
#� VIV%\ We`I `ji;tikke-9 If TO 3 b 6R ' THICKNESS MATERIAL
Company Name it. ft / in. y1 S c
16:INNER:CASING:OR TUBINGi(geothermal cl(oseedd=loop)
2.Well Construction Permit#: 3 5 3 0 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fr. ft, in.
3.Well Use(check well use): • • ft, •ft. tn,
Water Supply Well: 17:SCREEN
,. FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, fr. •in. -
❑lndustrial/Comniercial ❑Residential Water Supply(shared) 18:GROUT `
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Zt, ft, beivol M'lE mot_ .
❑Monitoring ❑Recovery ft. ft. �
Injection Well: , ft.
❑Aquifer Recharge ❑Groundwater Remediation '
.19.SAND/GRAVEL PACK(ifnpplicable) ;_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. '
❑Geothermal(Closed Loop) ❑Tracer r20.DRILLING LOG(attach ddditiorial sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type eraln size etc.)-
rt. ,66 R. r-t-4 C 1 ./
. 4.Date Well(s)Completed: I I IA 12-3 Well ID# • lb ft. 20 ft: '
iti+/`ow" .Icy /51a�e
5a.Well Location: :q� ;2 b ft' �00 ft' b Ue 51 e1 -e
ft. R.
James Orroc,L.; •
-
Facility/Owner Name Facility ID#(if applicable) ft. H. '
1 e 62. t 1. Lin
ft. • Z G f"
7 i di:'--
Physical Address,City,and Zip
ft. ft. y',
Li
D r('
.54-a►� fir,\Z z1cREl►�ARxsi_>. D13`::
County • . Parcel Identification No.(PIN) inttor, ,!i.,-i:7),,,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
1sDv 01 N 60tSSO1e W :i II /e. J2S
6.Is(are)the well(s): ePermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or difiNo ISA 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 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: �Q 24.SUBMITTAL INSTRUCTIONS
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')
' 0 24a. For All Wells: Original i form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+7
11,Borehole diameter: b $ (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: At e-..), 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
13a.Yield(gpm) 3 Method of test:
r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 14 r 14 Amount: 1 P h'14