GW1--07862_Well Construction - GW1_20231205

W 1.1,1,1,4.Y1"l I tU L.I IL AN KCl6ClY1U)(li W-1) For Internal Use Only: .
1.Well Contractor Informatio ••k. .
14e1V 1r•1 1 GI v i rs 0 e1 cC. �I �b1 14c`WATER ZONES.
FROM TO DESCRIPTION
Nell CowactorName eft., ft. f 3 „,'
�r 0Gr • Z1Vt. ft. I�
NC Well Contractor CertificatioRNumber t 15::OUTERCASING1formulti-cased4ells):OR LINER(if Bp"licable) -
p p`4‘‘1% p y��` ' i r-` 1 �,- FROM TO DIAMETER THICKNESS MATERIAL, p
Company Name
16:INNER:CA G: RSIN O TUBINGi(geotheriiial closed+loop)
2.Well Constrnclio Permit#: ,Z n " 2-1 C% FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perinits(ie.UIC,County,State,Variance,etc.) ft ft. 1 in.
., 3.Well Use(check well use): • ft ft In.
Water Supply Well: "17::SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. ,in.
O Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. ;in. .
❑Industrial/Commercial. ❑Residential Water Supply(shared) 18 GROTTY::;::
' *Irrigation ❑Wellss>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 'le' R. Q�nerry%AV Vt✓0 c
❑Monitoring ORecovery ft. it. '
Injection Well: '
ft ft. ,
❑Aquifer Recharge °Groundwater Remediation
°A uifer Storage and Recovery ❑Salit>i Barrier :19:SAND/GRAVEL PACK"(if applicable)`:�:`' _':`-.=.-•,:-�:-. ".'s; : •".:- _.
tl g tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer :-20:DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solU/rock typo grain size.etc.)
0 ft, ifft , ,fetir9Gel a[0.v
4.Date Wells)Completed:�Q ell ID# %6 ft �`� e` ,5'&
5a.Well Location: < ,- L1 t ft . 300 n• b • e s {ck�e`
Facility/Owner Name Facility ID#(if applicable) it.
ft. ft.
Physicali �Address,City,and Zip tb�• tt�����e p� T,�� nft rr dd�� rc I 7
' V�\cr.—% t:8"�o Cr1— �U`1 fi 27 REMARKS': : , .11 :1, 'of':a LQ�?
County • Parcel Identification No.(PIN) 1 IOt-f-.,,;;:i,.a P:,..,0.6gealsj Urea
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWO/� r
(if well field,one lat/long is sufficient) 22.Certification:
35,165°' 1 N gi0o(4g2)o W % IS 12-. tti t
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Connector ace
By signing this forma I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or No 15A NCAC 02C.0100 or 15A NCAC102C.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: .10 6
t (ft)
For multiple wells list all depths if different(example-3©200'and 2®100� Submit this OW-1 within 30 d lys of well completion per the following:
10.Static water level below top of casing: 0 / (ft) 24a. For All Wells: Original[form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 4 / �(in.) 24b.For Injection Wells:Copy to.DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ilk\M'• 11
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) G l r Method of test ;erf' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 14T. 4- Amount: 1 clin#
1