GW1--00284_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ( _
Kek) l1^% S3e\L (&cit,y ,". 4 e•C,)(-,SC,'r1 14.WATER ZONES
Well Contractor Name 1_ FROM TO DESCRIPTION
; on.L ft.
2_0 '(, .Z;,,koft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased}yens)OR LINER(if ap Ruble)
-• f\N v��\ \3.�c,1 b�- i 1 r\rN FROM TO DIAME ER THICKNESS MATERIAL
Company Name i�‘ ft.
Li 5 rt. t %�i n. , r 2,S I�C
, YY hh '.t t, qq 1 16.INNER CASING OR TUBING(geothermal cllosed-loop),
2.Well Construction Permit 14: (:,,1-II1.ti Ll�-2(:73,b`)\-4() [ROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1G County.Stale,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 ❑MunicipaVPublic rL ft. in.
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT❑irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL _ EMPLACEMENT MET OD&AMOUNT
Non-Water Supply Well: b ft. 2:- ft. c3�.rwt.li _per
OMonitoring ❑Recovery ft. ft. r
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity 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,hardness,soil rock ee In s1>e,etc)
C) ft. /O ft. q rit\I S cin I°fife
4.Date Well(s)Completed: 0-1 j S-j -3 Well ID# /C) ft. 2.0 ft b>a_vow` 3 c,-.),
5a.Well Location:
. .-i 26 ft. ft.
I^e-aL !:i 1 e'� ,
1�e.c..k. Y xcA6 1.-): 3 b ft. ,3 03:), 10 ft. ‘ut� ioc •
Facility/Owner Name Facility ID/I(if applicable) ft. ft.
i o&.d t Z3 e•She,l Ch,:,r-t 9.8 ft. ft. !. _
Physical Address,City,and Zip IL ft. r ‘'"�-'L i ��E
COb Ckw-Y"l-I`_i 21.REMARKS
. 11l N 0 ; 2024
County Parcel Identification No.(PIN) y��,
"yi rfi.S..f.:1 r r rn "a fl l/Ga
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C WC/:50G
(if well field,one tat/long is sufficient) 22.Certification: �/� rr
Sg ,1..-t 00 5 N � t;7 t1 ES 1 W 2.- Z1._________ fZ iv-1'Z,
6.!Wire)the well(s): VPermanent or ❑Temporary
Signature of Certified Well Co tractor Date
By signing this form,I hereby certify that the wel(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or allo 15A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out krtotm 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 aphis 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 co 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
s
9.Total well depth below land surface: t b (ft.)
For multiple wells list all depths if different(example-3 a 200'and 2Q100� Submit this GW-1 within 30 days of weH eompieaun per the following;
• 1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: _3 6 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
• If water level Is chore casing use"+"` hh
11.13orehole diameter /�i (in.) 24b.For Infection Wells: Copy to:DWR,Underground Injection Control(TUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: At1 r �c,,,--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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPO:Copy to DWR,CCPCUA
13a.Yield(gpm) 'CI Method of test: }/�'[ i Cl Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 01 ( '4 Amount: I r A-