GW1--00984_Well Construction - GW1_20240209

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• WELL ICONSST:"UCTION RECORD(GW-1) For Internal Use Only: ' .
1.Well Contractor Information:
,.I e F f c e j <rl. U7C er 14:'WATER ZONES (:.
'Nell Contractor Name = FROM TO DESCRIPTION �"'
�/ `:' 0 ft. fr. q{G1 F a j 02 3 o 3 /5
NC Well Contractor Certification Number • 15::OUTERCASING(for Multi-eased wells)ORLINEER(if ap lienbie)'--:':.'`::::
// + FROM TO DIAMETER - THICKNESS MATERIAL
,Z0 rr) .U/s• wed/ 9,r1C1iv, z/ac. .1., / ft. 761 %in. v<� 5 pvc
Company Name
/ 16.INNER.CASING:OR TUBING(geoth e-rmal•cl osed=lo op)'':
2.Well Construction Perinit#: . . 1 0 C./ t. 7 j �(0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft. in.
T 3.Well Use(cheek well use): ft. ft. in.
Water Supply Well• 17:SCREEN .,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Oft. /3e.7ion ile pew red
❑Monitoring ❑Recovery ft. ft. �/
Injection Well:
ft. ft.
ClAquifer Recharge OGroundwater Remediation
`:19:SAND/GRAVED PACK Of applicable)"".-_- .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer ,20:DRILLING LOG(attach additional sheetS.if necessary) -
FROM TO DESCRIPTION(color,hardness.soWruck type,grain size.etc.)
0 Geothermal(Heating/Cooling Return) 00tthher(explain under#21 Remarks) D ft. tt. Clay
4.Date Well(s)Completed: I-sal -a tell ID# n�' ft. 65' ft. ,f �j f.o,,i e�
5a.Well Location: `±�- tt. . +�� fL G�( e a°,
- t''.'I I e 1 C�d , 17�b ft- Noe,- gyred. �,..
Facility/Owner NNJ(ne Facility ID#(if applicable) ' fa ft.
,5 DW -S74-eph ens /e/• ft. ft. £..., yNt,
Physical Address,_ City,and Zip �/� 2 ft. ft. 'r l, -^lJJ L..t' V "
Mec_/fte), bk.,- 013— ©61I-3 -21-REMARIGS:_ _ . • I'•ED 0 (4.Zt;2, .
County bk.,-
Parcel Identification No.(PIN)'
• trtOrrr ien Prtcaiisirtg Ufiti '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e*:,C,;:.°'J.2
(if well•field,one latllong is sufficient) 22.Certification:
gleA4
6.Is(are)the well(s): manent or OTemporary S at Certi Well Contractor Date
_ f By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ISO 1SA 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 remark 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 G '-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
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9.Total well depth below land surface: ` v 0 (f-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3cu 200'and 2Q100')
+
+ 24a. For All Wells: Original•form to Division of Water Resources (DWR),
10.Static water level below top of casing: �J (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+''
11.Borehole diameter & /� (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: PO fL ct 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
�+ Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gpm)Yield `O l Method of test: //
13b.Disinfection type:ht /1 l" 4 Amount:_ 3 p/rJ `LL