GW1--00985_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • -
1.Well Contractor Information: ,
Jeffrey-lee c e r &Act , Pre C e ,14::WATER ZONES::: 1'-
Well Contractor Nam FROM TO DESCRIPTION
. ft. ft. '7 Ol 175 , 'D /05 / eo
�6Do2 ft. ft. I. ,5?".5 / 90 , a
NC Well Contractor Certification Number
'15:.OUTER4CASING'(for malts-cased.' lis):OR LINER(if'ap ►icable)�=. -_'
FROMMATERIAL
V.Z• in e-c af'5 w-e l/ D1-, (I r/ , -it4 v ft. TO rt. 6 DIAMETERgy s/
in. 2 5 S 1 J°v c
-f, Company Name
/��y
f ti :'16:1NNER'.CASING:OR=T[IBING:(geotherinal'closed4riop)?. .- '' '' '
2.Well Construction Perhut#: - L / t3 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pern<I C V ills(i.e.UIC,County,State,Variance,etc.) ft. ft• in.
3.Well Use(check well use): ft. ft in,
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public ft it in.
❑Geothermal(Heating/Cooling Supply) Lte'Residential Water Supply(single) ft ft in, -
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑Irrigation - ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft' g 0 ft' Ser rra.& eecr e_d
❑Monitoring ❑Recovery ft. ft. Y
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-'19.SAND/GRAVEL PACK(if applicable) .1, • -
❑Aquifer 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'(attuch additional sheets ifnecessary)-::: ... -. .: - :-.
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solUrnck type min size,etc.)
p, O ft' aO ft. /`P / eta
4.Date Well(s)Completed: /s' p "�q Well ID# ,A 0 tt• 6 p ft ,°- t 6 -,
'\5,,.,�W�elll�Location: /+`:s� ) 0 ft. �j 5 h' cy�93 e,,e, &,,,_ ,
►117t1-s IdCrS W- flCfl-c t'o C it o2 t�l�� QJLice _.�zn. G .-�.
Facility/Owner Name r Facility ID#(if applicable) ft. ft. K a a -I w ' V MO
7o 19 hlix-mb�'t'-h7 iM - ft ft. i Lt3 0 a ?JZ^.
Physical Address,l City,/and Zip
ft ft.
Me�.l Lei, bGt l�- 0s J 5 1.1i ..�5 21:'REMi1R1(S;_ =s':.. ;.• t-' :as ,^9a®:t: l�FLIi::
CANCOOG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: -
3 5 3 '7 / , N Y o . J O.S 023 W ar, -� —N_
6.Is(are)the well(s): l 1° manent or ❑Temporary StiEc
f Cc ' d Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance,wit/i
7.Is this a repair to an existing well: ❑Yes or 1214. 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 information and explain the nature of the of this record has been provided to the well owner.
repair under#21 renrarla 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 CIW-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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(0200'and 2@100) •
t ' ^� c 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7 J kit)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+•'
11.Borehole diameter: 6 A - _ (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
�Q Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /l e174ei r y 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) /0/� Method of test: TLi I
I//^ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: / /71 Amount:3 P t'11 r S