GW1--01008_Well Construction - GW1_20240208

WELL,CUl'INIKUC1"1U1'I{EUUKD(L,W-1) Forinternal Use Only:
1.Well Contractor
Information: .
• [eFfrey am[ / •GI�PY f��Lf�,'�) M/�� 14WATERZONYS We1lContracrorName FROM TO DESCRIPTION
y & o2. ft .
ft. ft
•
NC Well Contractor Certification Number
G� / // (/� :15.:OUTER CASING'.(for:multi-cased wellsrOR LINER ff'afl Ifiat7IAL
te)`:::i:1''....,:•-;:''.
FROl//• (— Met,/ (1rs Weil[ //rig It(in tv .Z/Ue' 4 11 ft. �(•'a ft / i/,ia im i�5 1 TO DIAMETER THICKNESS
Company Name ,/ ! LO /75
16•INNER;CASING:OR TUBING:(geoti erinal closed=loop) r..
2.Well Construction'Per •
mit �' FROM TO DIAMETER TIHCICVESS MATERIAL
List all applicable well construction permits(Le.WC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): . - ft •ft. tn.
Water Supply Well: l7:SCp EN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft. ft: .In.
❑Geothermal(Heating/Cooling Supply) IllIttIrcrential Water Supply(single) R In. -
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑irrigation . . ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT"
Non-Water Supply Well: 0 ft AO [t 95)-1.1. 42 ,
❑Monitoring ❑Recovery ft. ft j
Injection Well:
ft ft.
❑Aquifer Recharge OGroundwater Remediation
"49 SAND/GRAVELPACK(if applicable),;:-'7:- - .. '•:
❑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(atteeti addttioa1 sbeets:ifaeeessary) :.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color.hardness,soi0roekt type.eras size.eta)
4.Date Well(s)Completed:/- -0-23 Well ID# .2 6 ft rt. U.5_2 e,, s�-
5a.Well Location: :, ,/) 2 n• ,3 ot9 c. d 4 a e 1.
--g-P
II ty/Owner Name Facility ID#(if applicable) ft. R. I7s�' E 1VF�09�p �0L, l� sfe�>° gd• ft. ft . .�
� S 'ty
ft. ft• FEB 0 8 2024
Iirtagte+n PraCtafiltii Ut:
County Parcel Identification No.(PIN) r.`vwCW7.Qw
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3418 86 /6 '7 N 80. 301%I4(3 w 12— -.23
6.Is(are)the well(s): ermanent or ❑Temporary Cart' Weil Contractor Date
�/ ' 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 gdNo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
--Is•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 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 having the same You may use the back of this page to provide additional well construction info
construction,only 1 GWl1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: , "'�f�, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V (ft
For multiple wells list all depths ifdifferen:(example-3Qa 200'and 2©100') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3 I!�0 (ft) 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- �� (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: D 7 i I'/tj 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable;d rect_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
13a.Yield(gpm) Method"of test: .f{�
13b.Disinfection type:N l f 1 Amount: 3 /0r !7 7(S