GW1--00986_Well Construction - GW1_20240209

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WELL CONSTRUCTION RECORD D(GW-A) For Internal Use Only: .
1.Well Contractor Information:
\Tei- rCal/ /eze.RP, He. P/, ji//1' -14:WATER ZONES . :.• x :: .
Well Contractor Nana FROM TO DESCRIPTION
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ft.
ft. 5 o i®S� rho rc
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NC Well Contractor Certification Number • 15.:OUTERCASING'(for multi-eused{Yetis)OR LINER(ifap licable)>':';. ;.-'. . '
TO DIAMETER THICKN
9)14, /// /u-1);5 wee/ /J r/�-C i n L%uL j' (i, tft- J� ft to in. I t MATERIALE� P�C
Company Name ^�
.-16:-INNER,CASING:ORTIJBING:(geothermal-closed=loop) .- t
2.Well Construction Perinit#: :,e"61 i 3 8 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
a 3.Well Use(check well use): ft. -ft. in.
Water Supply Well: 17G'SCREEN :.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) t idential Water Supply(single) g• ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) i8 GROUT
❑Irrigation ❑Wells>100,000GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft, .2 D it N.04.2 aru /J 9 ct i e
•
❑Monitoring ❑Recovery ft. ft. U
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation •
_19 SAND/GRAVEL•PACIC(if applicable)---:.:--:' ....- :a:;-. .::.-s_':; --: ..
❑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 20dDRILLING LOG(attach additional sheets,ifnecessary)'.:..--.- . : .:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness son/rock type grain size,etc.)
0 ft. a o ft. Wed C A V
4,Date Well(s)Completed: /'/5 "or-, Well ID# 01 O ft. y_5 it fi c
5a.Well Location: '+„ ( C ft. 5 v ft. e 6 -
G L04-- q so tt, a D 6t• Lot.*e U�
[Facility/Owner Name Facility lD#(if applicable) ft. ft.
tt ft i �CL.L. �s1E F b
d'�18 �m �fr h �d —
Physical Address,City,and Zip ft. ft.
Lr h ! n
• ' 4:'21 ti1R ; . > _� 0 UL .
rii& _ ter bv4 es i5 I /
County Parcel Identification No.(PIN) S`:6C77..'i ;(^'1 .'72_.:.- („1,err •
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: G1/QraO
(if well field,one lat/long is sufficient) 22.Certification:
, SQ_3 71e& N Ma 70.5 W 7u, /-/5-1.24+
6.Is(are)the well(s): Prgnanent or ❑Temporary tgna of C 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 12No 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 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 G�-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: o 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 e@e 200'and 2@I00')
. , level below topof casing: a� (ft) •
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level above casing,use" " Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f watt
✓ 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: to �f (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: W0-A,42:/'9 V 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: I.
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
��1 t Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13a.Yield(gpm) 3 �i Method of test: s 711^
13b.Disinfection type: ri/1 7 Amount: Pf n��
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