GW1--00964_Well Construction - GW1_20240208

W L+,LL UU1v b 11KU Uf1UNV RECORD(GW-1) For Internal Use Only: ,'
1.W 1 Contrac r Information:
a �� 11 AG-5
A 14-WATER ZONES
e Contractor Name FR M TO DESCRIPTION
: ( fr.
N Well Contractor cation Number �'
_ u.t[1 S C' ' A I `l :FR._OUTER;CTO (for multi-Msedwells)`ORH:CKNES(Ilan MATERIAL`.
Company Name v art
[GAR-
i9 /6 w in- 1 I J P V
as-aui
16. R;CASING:OR-TUBINGi(geothermel closed-loop)2.Well Construction"Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft ft. in.
3.Well Use(check well use): tr. •ft, re.
Water Supply Well:
❑A Cnitural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
!F ❑Municipal/Public It. , n• in.
['Geothermal(Heating/Cooling Supply) Residential Water Supply(single) _
ft ft in.
0 Industrial/Commercial ['Residential Water Supply(shared)
lb:GROUT.:, -
['Irrigation ❑Wells>100,000 GPD . FROM TO `MATERIAL EMPLACEMENT METHOD& OUNT
Non-Water Supply Well: /'� ft a� ft• cn L, - ( 1_ ID JV�
❑Monitoring ❑Recovery (f tt ll�li iC>
Injection Well:
['Aquifer Recharge ' ft. ft.
4 ❑GroundwaterRemediation
['Aquifer Storage and Recovery ['Salinity Barrier 19.SANDIGRAVEL PACK('(applicable)" •; .
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ['Subsidence Control ft. ft
❑Geothermal(Closed Loop) ['Tracer ':30:DRILLING LOG(attacb-additional shetts3ttiecessary) .:.".?..-:::::.=_ . .:. -:
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIO (color•6 rdness sowrocktype,grain size etc.)
f4 O ft Fk t ` ( 11 ',� '�/i o, ,,,,A
4.Date Well(s)Completed:`I••3Cr-ta3 Well ID# Left• jrj
ft. ' 'I `'Gym( vV�-ems I .6kete+
Sa.Well Location: gp ft
. 1 Q) ft /'1 (saCOA - bit
FacilityKlemer Name clit ID# if applicable l oa ft cn ft.
i
?Grl(u)( k'N4-baRc.
l tt ft 147--
Pit � ! � � -
Sica�A(ddr ss,City,and Zip ft. ft ! 't e7- t>L al
�i On
County Parcel Identification No.(PIN) I CD g ZOZ4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lre>;cr e.at(2t1 P:GC;sMcicto U'
(if well fieldGone lndlong is suf rcient) j/� Q�j 22.C tifeation: Dw.��
N go
uvin,47, ,
i(,_ 36-0)3
6.Is(are)the well(s):2 ermanent or ❑Temporary Si at re o Certi ed Well Conaacter;: ,:• : - `\• ' Date
By signing thisfonn,I hereby cert(that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or Apo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction I formationlain 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:
S.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:
1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Lk (AD
Submit this GW-1 within 30 dais of well completion
For multiple wells list alldepths ifdifferent(etample-3QZ00'and 2®100� (ft) y p tion per the following:
10.Static water level below top of casing: 40 ,,, ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
' ((water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ` 1 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IOC)
'� Program,1636 MSC,Raleigh,NC 27699-1636
t
12.Well construction method: --
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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) 1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
b
13b.Disinfection type: 'i Method of test: `^`"
Amount: