GW1--00983_Well Construction - GW1_20240209

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ' •
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1.Well Contractor Information:
Jeffrey lL,,c ✓7 er
Well Contractor Na a FROM TO DESCRIPTION `jk Li to ft., rt.
J�J ®�7 [/$
ft., ft.
NC Well Contractor Certification Number 15::OUTER CASING(for;multi-eased.wells)OR LINER(if'ap lieable))•"/. - : .
�, L r In w l/,"s r.�.Je!/ �fir;c l r'n� .�jvC ,FROM ft. n7�ft. DIAMETER
�$R in. O G� � P(/
KNESS MATERIAL •
Company Name
�f/� / '] 16.INNER.CASING:ORTUBING(geotbe'rtnalclosed=loop):`:.';.
• 2.Well Construction Per)nit#: - . 1 (,/ / -'f �y S/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft. in.
OGeothermal(Heating/Cooling Supply) liatilsidential Water Supply(single) ft ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT •
Non-Water Supply Well: L`) ft. O ft ` fi t peu f�ocL
OMonitoring ❑Recovery ft ft /
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -19.SAND/GRAVEL-PACK(if applicable) . - - . . -
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :20.DRILLING LOG(attach additional sheets if necessary) •. '_:-...•._ ;'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,main size,etc.)
r �� ® ft. oS 0 ft. Red L�
4.Date Well(s)Completed:/ " Well ID# a 0 ft. ik(� ft. ,�� " c-t.. .d//3Lhtc-- 5Z.Z.,
5a.Well Location: ,,/�`,�i 1 I I� 0 ft 7.2 ft W j, � 6� --
nrrrls�uLlole/$tVT r�Gtic b 1 ft0Fyft c `"Y 6Az
Facility/Owner Name Facility ID#(if applicable) ft ft.
ft.loZ/o I� n "h
a -16r f Ad ft ' r,.�, :.,.,, �.- , ir ,r'.;,
Physical Address,City,and Zip ft. ft. • 1, \i✓.O.'1....ii '' L..'te.?
211-REMARKS..:.z: ..._ H^rl'- ID,A .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 12i4v;,tc;0
(if well field,one lat/long is sufficient) 22.Certification:
35 3 '765o N got 9°53 3 W / 7 �� 7- L�
6.Is(are)the well(s): anent or ❑Temporary
P of Cer' ed 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 fil1'ilii 15A NCAC 02C.0100 or ISA 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 G,W-1 is needed. Indicate TOTAL NUMBER of wells
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3£c, (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 t@200'and 2Q100)
• , 10.Static level below top of casing: 3.0 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static
taticr el wateris above casing,usle�top • Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: CO � (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Re)f'r! 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
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) (9ii�// t Method of test: Ff 1 r' �/
13b.Disinfection type: /4 T/1 Amount:3.j f) Lzr