GW1--00988_Well Construction - GW1_20240209

VVLL&I L..U1'4 'nut.,'Jun tumutnuy(tiW-I) 1'"orInternal Use only:
1.W 11 Contractor Inf ation: V .
jjj���J1` `l
}/7 5 •lt"WATER ZONES '.`r. ,.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number 1 r�` 15..OUTER CASING'(ror;inulti-cased welis):OR LINER(If ap'licable)
` y V`\ �� l \(1 U\ Air\
{ FROM TODIAMETER ' THICKNESS MATERIAM
' JU 1 1 V�, U99 vv+(/ U P1 ft. "7(� ft. in. %9 'I 94424
Company Name ` l ) 16:INNER:CASING:OR TUBINGi(geothermalclosed=loop), l.
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2.Well Construction-Permit#: 1°CA 4 1'1-3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC County,State,Variance,etc.) (� ft. /6.0ft. tn. c f 6P?/C
• 3.Well Use(check well use): • fa -ft. �1 in.
Water Supply Well: 97:SCREEN..,
., FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL I
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) LDResidential Water Supply(single) ft. ft. in. •
❑lndustrial/Commercial. ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL pEMPLACCEEMENT METHOD&AMOUNT
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Non-Water Supply Well: D ft. (D O ft. ;iceoeNe'.5 Pau/
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation
DAquifer Storage and Recovery ❑Salmi Barrier :19.SAND/GRAVEL PACK(if applicable):': '- :.` "•".:"' .
q g tY FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage fr. ft. i
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20 DRILLING LOG(attach additional sheets if necessary) .
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soll/rnck type¢rain she eta)
4.Date Well(s)Completed: 1111 L l23 Well ID# ft. ft. !
5a.Well Location: ft. ft.
Jc7SE0� (-euP�-Q:,. ft. it .gE ,,, +VE D.
Facility/Owner Name Facility ID#(if applicable)
Q9o1 P6°v;Gee l-tc o F i.P s1 Ln jte4o l I JC ft. ft. I-Eta 0 9 2024
Physical Address City,and Zip -IS2 (f�� Z7o ft. ft '
4 . - m bar 1- : 1 a3 t - 3� 2l'RFMARKC 17tn:�r[A3+i rcua
County J • Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifies•'•• I e1
N W " /t07/Z?
6.Is(are)the well(s): rm eanent or ❑Temporary Signature o Certi We on cloy Date
By signing this form,IJhereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: es or IfiNo ISA NCAC 02C.0100 or 1SA NCAC102C.0200 Well Construction Standards and that a copy
If this is a repah;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. i
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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovef in Remarks Box),IYou may also attach additional pages if necessary.
drilled: i� 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: d2 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ft-different(example-3®200'mud 2®100')
3-6 tit)
24a. For All Wells: Original!form to Division of Water Resources (DWR),
10.Static water level below top of casing:
, If water level is above casing,use"+" Information Processing Unit,1617'MStr,Raleigh,NC 27699-1617
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: .1(-)i( Ai .1 N 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) J 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) ( 5.- Method of test: PCB Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 9T/77' Amount: 3,✓tu