GW1--07867_Well Construction - GW1_20231205

.. a ate..—a avi. a�a.vvi�,v •v..—a r v.iaaw.uua a.ov vaaay.
1,Well Contractor Information: •
TeFFre y 7&c 4 er I4i WATER ZONES s
Well Contrac[orNaine FROM TO DESCRIPTION
b o a ft. ¶/ ,i qsl
[t. ft.
• NC Well Contractor Certification Nu •
mber .15::OUTER CASING(for:multi-cdsed:wells)':OR INNER titan'IIcnble)
V /' /1 u//1 3 J // D fl/'//j,N 2-/VC. FROM TO DIAMETER
DIIAM`ET/ER THICKNESS 1 MATEEIRIAL
• Company Name < !/ L , � ' ft. cis f G (o !g•in. ,�,2 s /"I/c
` V / 16:=INNER:CASING:ORTUBINGi(geothermalclosed=loop) , -
2.Well Construction Permit#: J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): - • ft.•
fr. in.
Water Supply Well: 37:SCREEN
., FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public ft. ft. ;in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. ;tn. •
❑Industrial/Commercial °Residential Water Supply(shared) :18 GROUT
0 Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge °Groundwater Remediation '
DA uifer Storage and Recovery ❑Salmi Barrier :'19:SAND/GRAVEL•PACK(ifiipplIcable)' _. r':::_:.;,`•.:;.^ ;. :-
q g tY FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Test ❑Stormwater Drainage ft. ft.
°Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer :10 DRILLINGLOG(attachradditional sheets;(necessary) -.
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(coot/or,hardness sowracktypte/acalnsize.etc)
0 ft. ` fJ ft. 1 ..eGLe.e, C e,:k/
4.Date Well(s)Completed:it"'7 - 23 Well ID# /3' ft. ys ft. ,e -Si_ /P
5a.Well Location: :.� L� ft. a Dp 13 C�e G 4 l
31-C
Facility/Ot nerName Facility ID#(if applicable) fL y'j--(fit, ;:,Ii
/im. & A" „ ft. ft. ��yy +`
Physics,Address,City,and Zip m� f. ft. U L U 5"2023
2]cREMARKSs:
_14/)r0 Q ' ' l Q. 1 rnu1 n ioir n er c ,:gig UsIX
County Parcel Identification No.(PIN) ' (lir'012,C ;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,oneiatllong is sufficient) 22.Certification:
3so /633 , N g d 3 ' QQ 0 w , �, - 6_ it— r]`�a_3
6.Is(are)the well(s): ermanent or °Temporary Srgna of C ed Well Contractor`'`�� Date
By signing this form,Ihereby certify diet the well(s)was(were)constructed in accordance,with
7.Is this a repair to an existing well: ❑Yes or ,1$Fo ISA NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a copy
If this Is a repair fill out known well construction informal-Mt and explain the nature of th a of this record has been provided to the well owner.
, repair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
, 8.For Geoprobe/DPT or ClosedeLoop: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 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 • (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)
( ) 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/"+'
(O Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ./6 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
n Program,1636 MSC,Raleigh,NC 27699-1636
• 12.Well construction method: d to ry 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: ,n 24d.For Water Wells producing,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 5 Method of test: /eT%r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1T T#1 Amount: 3 p/il 74s
I