GW1--01005_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,
1.Well Contractor Information: �If� �
- eFFrel /�L[C��Fr'f F�/t /O,-/1e'� 44`WATER-ZONES .._
Well Contractor Na FROM TO DESCRIPTION
. Li&C7:� n 1t S�� �S 1�0
ft. ft.
NC Well Contractor Certification Number
15::OUTER:CASING(for multi-cused;wells)-OR LINER(if a livable)•:.: •:::-.
27 L. /17 t t l/11 we!/ • V rt tL6» X„/c. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ,v -1 / ft. y3 �ji 1/8 in. , vc
'16:=INNER;CASING:OR:TUBING:(geothermal closed=loop) 0
2.Well Construction Permit#: / "' la 3 FROM _ TO DIAMETER THICKNESS 'MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
t 3.Well Use(check well use): ft. •ft: 1 in
Water Supply Well: 37sCREEN`::. s
OA iCUltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑M��uunicipalPublic ft. , ft. ;in.
, OGeothermal(Heating/Cooling Supply) PiCesidential Water Supply(single)
ft ft. ,in. •
❑lndustrial/Commercial ❑Residential Water Supply(shared)
0 Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. oZ v ft. Ve,r40,7/
44.[Monitoring ❑Recov ® ��eY ft. It.
Injection Well:
urfer Rechargeft, ft.
❑A
q ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SANDIGRAVEUPACK`(itaaalicabiey: : ':: ., ,•
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
C lExperimental Technology ❑Subsidence Control ft. ft..
❑Geothermal(Closed Loop) OTracer ':20:DRILLING LOG;(attach addition®i sheets if tieccssary)
OGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness,soWrock type,grain size etc.)
Us ft. 1 S. ' ft. fed e.L'-/'
. 4.Date Well(s)Completed://'a.�`.23 Well ID# l 8 ft. 493 ft n�O G _ - f�Sa.Well Location: :- "/t 3 ft. /2©ft- P4:"?- ',-eKPJ/17/.., ./7 A`©C/7
tvu j n e L1, b r e_- 1,90 ft: 2 Oo ft. Dr,tcls !cc%/ 13L�P Gfr
Facility wner Name Facility ID#(if applicable) ft. ft.
r9 o / D awl dJ D,Sd ft. to
Physical Address,City,and Zip ft. ft. FER Q g 2024
ca_b a_rr lei' REIVIARKSt
County Parcel Identification No.(PIN) inisaragen S fOCsegiP^y Us l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) e� 22.Certification:
3�J o.2 ga l,2 N &) C2 41,9 w
/��' �u� /t-a"i�3
6.Is(are)the well(s): f�Fermanent or ❑Temporary re of rtified Well Contractor Date
By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or 1t190 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 baying the same You may use the back of this page to provide additional well construction info
construction,only 1 GjN-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: c o 0
For multiple wells list all depths iifd fferent(example-3®200'and 2®1003 ( ) Submit this GW-1 within 30 days:of well completion per the following:
10.Static water level below top of casing: v (f,) 24a. For All Wells: Original form to Division of Water Resources (DWR),
' If water level is above casing,use``"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: lJ //$ (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Wn Ata/> 24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the
(i.e.auger,rotary,cable,direct push,etc.) PY
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) g D Method of test: iq /a�^ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /17H Amount: 3 pill-Fs-