GW1--00243_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.�Welll Contractor Information:r"^e\ckf (`, l‘c,. C eioNirt'� J a C...t:Sorl 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
9 5 ft. ft.
'2 D 3
ft. ft.
NC Well Contractor Certification Number p s 15.OUTER CASING(for multi-cased wells)OR LINER(iKap Iicable)
rC`1S y�,l,\)e`iC \ 'Se-\\ , `r.\\\.��5 FROM TO ' DIAM ER THICKNESS MATERIAL
J J`•_ 1`IN .7 �IOJ �J ft. LlI IL i p in. '_ V C Company Name -1 Gr e Z
Q 16.INNER CASING OR TUBING(geothermal closed-loop)
3
2.Well Construction Permit#: 1 2 3 Lig FROM TO DIAMETER THICKNESS MATERIAL
List all applicable welt construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
-
❑IndustriaUCommercial OResidential Water Supply(shared) 18.GROUT _
❑hTigation ❑Wells>100,000 GPI) FROM TO MATERIAL ' EMPLACEMENT 11 ETHOD&AMOUNT
Non-Water Supply Well: 0 ft' .2-0 ft. [3encn IIZ purapecl (J
❑Monitoring ❑Recovery ft. ft. L7 J
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer 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 if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardorss,solUrock type,grain size.etc)
a ft. /0 rt. rc.c ' c1Gy
4.Date Well(s)Completed: /0/5 I'Z3 Well ID# /O ft. - 0' ft. e Stone
5a.Well Location: ' ;-t 2 ft. �o ft. \_we. 5 1 ,
�.h`s`vS `�Gr" -0`J6%'-' I Cj ft. sooft- b\ve $1 c.
Facility/Owner Name Facility lD#(if applicable) ft. ft.
LibA.5 ®lA ttx.it5 ft. ft. °'...(...1.., VET-)
',
Physical Address,City,and Zip ft. ft. 4 N l
5' o,ra�/ 'LS Lk \ \ 21.REMARKS a Z�24
!ni,r,,,;
Y Parcel Identification No.(PIN) '
Count . ;,g rag Utrd
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
.20.".;
(if well field,one lat/long is sufficient) 22.Certification-
3 Ict2f4S N CBtst21 1SO wfro � fexiie"
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well 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 allo 154 NCAC 02C.0100 or 15A NCAC 02C.9200 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(GW-I 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: Sd0 / (ft.)
For multiple wells list all depths ifdiJferent(example-30200'and 2(a4100� Submit this GW-1 within 30 days of well completion per the following:
' r 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: -1 O "") Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+" I
11.Borehole diameter: 1 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
(� ,�i Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: F t\Y- s-•Y 1 N.---.) 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: 1 'r Permit Program,1611 MSC,Raleigh,'NC 27699-1611
136.Disinfection type: k k 4 Amount: 1 �`1r'1'l