GW1--01143_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECO (GW-1) For Internal Use Only:
1:Well Conttractor.Iuformation:
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.,JCo4T ReineC�ar' - •14.WATER ZONES
Well Contractor Name �] FROM TO DESCRIPTION
• o�V ft.• o74/Oft
• 35-35�1 ., •
fit fG
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NO Well Contractor Certification Number
t� � • 15.OUTER CASINO(for multi-eased welb OR LINER°rap licable) •
11.eLdMA.n Ere C.ker5 X . _ FROM. TO , DIAMLIER THICKNESS MATERIAL
C �Nnme
rt ft. in
ompa
(�L IL Q� 16.INNER CASING OR TUBING(geothermal eloded-loop) •
2.Well Construction Permit II: s • I PROM TO DIAMETER• THICKNESS MATERIAL
List all applicable well construction penults(i.e.Ufa County,State,Variance.etc) '/ ft W/_a ft• M r 4 ff in. �la. p fir+-
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3.Well Use(check well use): . It.
Water Supply Well: 47.SCREEN .
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FROM TO •DIAMETER SLOT SIZE THICHNESS MATERIAL •
• ❑Agricultural • ❑Municipal/Public ft ft. .. ia.
❑Geothermal(Heating/Cooling Supply) eltesidentiql Water Supply(single).• ft __ ft in.'
❑Industrial/Commercial . ❑Residentiat'Water Supply(shared)
18.GROUT
❑Irrigatiop ❑Wells>100,000 GPD • . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • • D.R, ,2,l ft. AteA4. jt e 1
❑Monitoring ❑Recovery ft. `f �1 rr-- Lf
Injection Well: /Ti'loi T'fAynQ -
• ' ❑A uiferRechar a ft. R
9 g ❑GroundwaterRemediation I .
19.SAND/GRAVEL PACK(ir■ppliuble)❑Aquifer Storage and Recovery ❑Selini Barrier •
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ' ft. ft
❑Experimental Technology ❑Subsidence Coutrol ft. ft
• ❑Geotherial(Closed Loop) . ❑Tracer '20.DRILLING LOG(attach additional sheets if necessary)
['Geothermal(Heating/Co iding Retum) ❑Other(explain under#21 Remarks) PROM • TO DE$CRiPTIQN(color,badness,sslUroek type,Lein rise,etc.)
ft. ft.
4.Date Well(s)Completed: a-8-a 1' Well ID#,+i4 3951 ft.
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5a,Well Location: ft.
.a hri 5 Cooper .y•.^ .
• Facility/Owner Name Facility IDg(if applicab•
le) ft. ft.
532 bohorme-foa.J 6parkt. NC. 016.73' ---ft. fit FEB : 2024
Physical Address,City,and Zip f. tt g,�,c���.(�
Ci Ile3k k,9 301#o71 as ge 21.REMARKS . e
County
Parcel Identification No.(PIN)
•5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(dwell field,one lhtilong is sufficient)
22 Certifica•on:
.31°dq,14-8 N Xl° gt S9 u • W
Et ,3.17aI { °� _
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6.Is are the wells: P ry
Is(are) () Permanent or. ❑Tam ors .Signaturb liftertifieif\Yell Contractor Date
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constructed In accordance with
7.Is this a repair to an existing well: .❑Yes or ,elNo• ISANCAC 02C:0100 0 7.5A NC Ct 02C.0200(Well Cv irnat the well)was(werection Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature elite of this record has been provided to the well owner. '
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•repair under 021 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rdniarks Box).You may also attach additional pages if necessary.
drilled:
�' �. 24.SUBMTITAL INSTRUCTIONS ' '
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-9.Total well depth below land surface: •o1Tb • (fO r
Far multiple wells list all depths If different(example-3©200'and2©100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: er t?) • (fit) 24a. For All Wells: Original'form to Division of Water Resources •
If water level is above casing,use"+"./ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617. • �WR),
11.Borehole diameter: t Is' (in•) . 24b.For Injection Wells:Co to DWR,WR,Underground Injection Control(IUC)
12.Well construction method: r° r`1 G t
t Program, MSC,Raleigh,NC 27699-1636
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(i.e.auger,rotary,cable,direct push etc.) •24c.For Water Supply and Open-Loop Geotherrtial Return Wells:Copy to the
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county environmental health department of the county where installed
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• FOR WATER SUPPLY WELLS ONLY: • •
/� 24d.For Water Wells.producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) [o Method of teat: 'G1 t r •
• Permit Program;1611 MSC,Raleigh,NC 27699-1611 i
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13b.Disinfection type: H 7// An.n.,,t• L2 A•O•