GW1--07864_Well Construction - GW1_20231205

1.-Well Contractor Inforll�uation: •
- Ve- e�/ �4��er ' P ./�/� �/7 /'/'/ e' 14:'WATER ZONES
Well ContmctorN tS FROM TO DESCRIPTION
ft. ft. /3, $
'1 6 o ..... ft. ft.
NC Well Contractor Certification Number e�^� n, 15;OUTER CASING`(for:multi-cased welis).OR LINER Erin'llcatile)
V. L. J Li.//1S Lae/� Vei 1l/Ii TO
- 4/c FRO"
/ it. /3 ft. !%DIAMETER
THICKNESS
in. id.2 �p
Company Name 7 v
16:3NNER:CASING:ORTUBING;(geotheh iial-closed=loop)
2.Well Construction-Permit#: -4� a C> 9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. R. E in.
t
3.Well Use(check well use): ft. .ft. ia.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici al/Public ft. ft, .in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. ;in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) ;18:GROAT
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&&AMOUNT
Non-Water Supply Well: 0 ft. , 0 ft: 92o-r, 10DGeit ..
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
:19.SAND/GRAVEL PACK(if applicable):" ='. - ;.-:. :.:'::.': :;z-
❑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 !'20.DRILLING LOG(attach additional sheets ifnecessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sal!rock type grain size.etc.)
'
0 f' 0 ft' Rea el�
4.Date Well(s)Completed: /I"/40 `6q3 Well ID# .26 ft. /3 0 ft sw,-t / 5 4.0 Lp VCt„Q Zek..
5a.Well Location: ;.;I: /3 a ft. /3 - % Lae G e
'�� afrY1 6 .1 t7 ". t,3 V'z V .e 6.. . -
Facility/OwneerName Facility ID#(if applicable)
ft. ft.
6S/, • C J i 0 L!/4.,e/I a.44, all' n r o(2 r Q . ft. ft. s A+, 4 1 "„...-
Physical Address,City,and Zip /�(�1 ft. ft. �'�' L . ;V
'�r// n (Ql)VI.j p 2l.REMARKSi_- 'DEe F�; j 2�„,� ...
County • Parcel Identification No.(PIN)
intOrirtalizn t7;';s;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D''Oj " '' Ut+~
ka
(if well field,one llat/long is�sufficient) 22.Certification: •
3,10 9,0 lis Q N ve,o '7 tj
3 © `GZ W .
t/--/0`,23
6.Is(are)the well(s): permanent or ❑Temporary of red ell Contractor 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 to ISA NCAC 02C.0100 or ISA NCAC.02C.0200 Well Construction Standards and that a copy
If this is a repah;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: I 1 3 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / D p (ft.) •
Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi(7erent(example-3®200'and 2Q100)
1 �„3 D (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
. If water level is above casing,use/"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: �� (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RA A 1-61/'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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 /if.1
/t�` Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test:
13b.Disinfection type: hi 7-A/ Amount:,3 wI'/j /' S
I