GW1--00955_Well Construction - GW1_20240208

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1.Well Contractor Information:s •
ZreFfre !uc%r / /,,3p,4 n bike •-14.'WATERZONES ,:: . . .. .,
WeltCgntractor Name FROM , TO DESCRIPTION
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ft. 1
NC Well Contractor Certification Number
DG/Y/f M / e� wed I / non/ / n 15::OUTER'CASING(foi multi-cased3fells)OR LINER(Nap liable)` '''•
z. /•I GL/ I s IN e 9,1-1 a n+- /t/c,F,y'm fL ' 7° It DIAMETER in. THICKNESS MATERIAL
Company Name v J / fJ l/ /� 0%� puG
�/ �y `16ANNER.CASING:OR,TUBING(Rao berival elosed406 -
2.Well Construction Permit#: :tt ` ,i / r/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County.State,Variance,etc.) ft. ft: in.
< 3.Well Use(check well use): - in.
Water Supply Well.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑M icipal/Public ft. ft. In.
OGeothermal(Heating/Cooling Supply) Ia?'Residential Water Supply(single) ft. ft. :in. -
❑industrial/Commercial ❑Residential Water Supply(shared) .,ab.
❑irrigation [Melts>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft.
ao .4-zrt,;:t: poavz.��
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL-PACK(if applicable) -:._
❑Aquifer Storage and Recovery • ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Starmwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. '
OGeothermal(Closed Loop) OTracer 20/DRILLING LOG(attacbaidditionaliheetslf necessary)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM To DESCRIPTION(color.hardness soa/roek epee pram size etc)
4.Date Well(s)Completed:/ 2 i28°'a,3Well ID# a 0 fL kho ft. ..$A,..// S tisVi e
5a.Well Location: :,-t 16 rt. gl 8 ft- , •
ZT d- Berl e4r/r gg ft. .3od' ' P Wee,-e G,t.a. .
Facility/Owner Name Facility lOP(if applicable) n R•
Kwil RpAzir) VA. \)30.-dACIAL) ft. ft. t..... ___
Physical Address,City,and Zip'1 �I2` ( ft. ft. ?n
U14 1,!9/ viz cp DI \ -2I:RE113ARKSi: - :Fga ::0-S. !_04.
County Parcel Identification No.(PIN) Lk.,- '.rr7 CSC
tis
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tar8� t
(if well field,one lat/long is sufficient) 22.Certification:
3'10 S a s??e, ' N 80. 7 0 '733 W � - /a -aY-
,23
•6.Is(are)the well(s): p ermanent or ❑Temporary f Ce ' ed Well Contractor Date
By signing thisform,Thereby cent@ that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 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 1 9W-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
9.Total well depth below land surface: 3 0 0 at,)
For multiple wells list all depths(fdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
(fL) 24a. For All Wells: Original;form to Division of Water Resources (DWR),
10.Stattc water level below top of casing: ��
If water level is above casing use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: /�0-f-cv'y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb,etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
qq r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) O Method of test: �/
13b.Disinfection type: hi / Amount:_-?/- ;01.11_5'