GW1--00952_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Informati n:
t-ewti n B k Crow lr. Jc:(,,kS(v.) 14.-WATER ZONES '' : :..:. _:�;. :.'::•.:_ .. . ,_r.;.: -:.. :. ,:-:;i: :. .
Well Contractor Name r FROM TO DESCRIPTION
.0-5 6 ,.'b ft.. ......1s. ft
NC Well.Contractor Certification Number 'l''Zt'ei ZS ft. !L f Yy
9 15.:OUTER.CASING(for multi-cased wells)OR LINER(If iicable).:::
1(\3i\v e-\` r,\k 1" FROM TO DIA..{I TER THICKNESS MATERIAL
`r` ` J ` e 0 i �q
Company Name +-` ft. s ` ft G i N 9, in. 1 a , pvc
16.INNER.CASING:OR'TUBING(geothermal'closed-loop)'= .=
2.Well Construction:Permit#: : 2 2 - 4 Ls i FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. rt. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17::SCREEN ::::_.., ,...:., :..•:• _
-FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothennal(Heating/Cooling Supply) IRRResidential Water Supply(single) ft. It. in. •
0lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: e) ft. .-LC. ft. i l —_
❑Monitoring ❑Recovery ft. fC
t l� T
Injection Well: ft. ft.
❑Aquifer Recharge • ❑GroundwaterRemediation
19.SAND/GRAVEL PACK(ifapplicable) .. - .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM . TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control rt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING-LOG(attach additional sheets if necessary);'' . - . _
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONE (color,hardness,so3llrock type,grain size,etc.)'
ELS4 0ft. i o rtIDt'id J i C I4.V4.Date Wells)Completed: 2,� Well]D# i7 d rt Ze, ft- 6•z.,wi S f
�Sa/Well Location: :p () ft. )LID ft der racy
♦[1Nick V J��Cnp 4ibft t S0ft- b`°Je '� IA4— '�CJ1 F,,NI -
Facility/Owner Name Facility ID#(if applicable) ft ft. L a ti J
B
5 iz, .Lzl^cigtU -y b r ft ft t N 4...A.,,e
Physicale � Acldress,City,and Zip q a rt ft. FEi� •0 8 9Q?R
•
kb INC D i 7 d b l-I-1 04 L1
County Parcel Identification No.(PIN) 171fGi7FISi leri 7'rCC n i,!r-4.
uitioineG
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
S. o t C(r N 8 C.�t`-18 1-1 6w r
--V- P,I,A4>/#9Z 1123 124
6.Is(are)the well(s): i9'Permanent 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 IVNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair:frll 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: pSV 24.SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: V (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiJjerent(example-3@200'and
� c6312 00)
10.Static water level below top of casing: 14 V (( (ft') 24a. For All Wells: Original form' to Division of Water Resources (DWR),
If water level is above casing.use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
+' 11.Borehole diameter: � i (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/A/�� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Jr' "ktl,r-V 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) .Z D Method of test: 4 \.-- Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: kr Amount: \ plr 1 `