GW1--00240_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor lnforman '
KeV•Pir. VIe\ ed Zi y • a �i0� 1
14.WATER ZONES •
FROM TO DESCairTt0;1
Well Contractor Name 'PS Cr' rt.
Z 03 G 220n ft.
NC Well Contractor Certification Number °` 15.OUTER CASING(for multi-cased wells)OR LINER gap liable)
D L i�v\, `S W e ` ri,1t, FROM TO it ` in DIAM a THICKNESS
g /Z c" r v Y(ATbER,IA/L
Company Name 1 fV. �s C
16.INNER CASING OR TUBIN (geothermal closed-loop)
2 - 2 03 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: in_
all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): rt. ft. in.
Water Supply Well: I7.9CREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
OGeothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. In.
Olndustrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation DWells>100,000GPD . FROM TO MATERIAL . , EMPLACEMENT MET OD&AMOUNT
Non-Water Supply Well: 6 ft. ��a ft. 13< t,r-u 4e ou
❑Monitoring DRecovery ft. ft. I
Injection Well: r ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
DExpertmental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTI N(color,hardness,soWrock type,grain she.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) tt R.
d l ``__ G 1`G
4.Date Well(s)Completed: 10/14 l L Well ID# f 7) It. -2l`j ft. .Dtl"L7it,'f C' 1/ /; c(Iz' 40V:'
5a.Well Location: :-�. 2.0) rt. 2 1:PC) ft. a_(U_ S ie`,
rl it rr , i\- s a T/V rvl)t� ft. ft. >`-; r_ s 5 ��'f"l
FacilitylOw7nerName�] J Facility ID#,(iferpPlibablo) ....- .r "S 'tt Li.
51 [. 17L.7 rvr% S%MVO c'S t . ,1`� ft. ft.
.��'ft. ft. . G1�� � � 2
Pitysical Address,City,and Zip A
On t o bi of'1�-v-t 3/1 2L'REMARI(S ,n'.:rar.c4:;.1 i t•..:-r-"+•',^.9 latf
County Parcel Identification No.(PIN) Csts'C.y'9.f:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:c r
a: IOU1t� ( `�N � 3�2 `3 w /16,--n t�l1'1-.)tot�.���`'' /0/�r� I�3
6.Is(are)the well(s): 8I'ermanent or DTemporary
Signature of Certified Well Contras
Dais
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance whir
7.Is this a repair to an existing well: ❑Yes or iri!Qo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Iftlrts is a repah:fill out known well construction ttiformatlon and explain the nature of the of this record has been provided to thew!'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 toprovide 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: 14.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2442® (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(arample-3(@200'and 21100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
. 10.Static water level below top of casing: 3 0 ( ) Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
If water level is above casing,use-+"1
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Ii.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: <1^ '.--Y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY; 241 For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) '2 0 Method of test: f"'
13b.Disinfection type: ? 1-1 Amount: I rj 1V'