GW1--01783_Well Construction - GW1_20240320

x.,s,eilia a Is.t/s..,I Wiwi ItEl-Ult1/(ls 1ii-1) For Internal Use Only:
1.Well Con actqr Information:
°5- "4//'11- ..••' "1th.4-///,,,.1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
-/4- ;tit" ft• ‘.:5‘.0 it' .„.4;
3
ft. ft.
NC Well Contractor Certifiraition Number
K2r j
. .
. IS.OUTER CASING(for nialti-cased wens)OR LINER(if ap ticable)
/0/4/ilei /./t/‘"el/ 7),///coo. Cd, FROM To DIAMETER THICKNESS MATERIAL
///1 4. W.. 30(...1 ft- 5 eXV.,,A*1-- /';',.
Company Name
. .., --c,--7..., 16.INNER CASING OR TURINGtgeothermal dased-laa
2.Well Construction Permit#:/tf,5.221.;-7 Yeti/2 -I FROM 'TO T DIAMETER THICKNESS MATERIAL
List all applicable nett construction permits(Le UK,County,State Varamee,etc.) ft. ft. its
3.Well Use(check well use): ft. ft. In.
----
Water Supply Welt' _17.SCREEN
-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ClAgricultural ['Municipal/Public ;•1 c)ft' '"?,,,d ft. V hi" ._:. 4i,•,) /4-1,(..:
OGeothermal(Heating/Cooling Supply) ,...' Residential Water Supply(single) ft. ft. in.
Dlndustrtal!Commercial ClResidential Water Supply(shared)
18.GROUT
Dlrrigation [Melts">100,000 GPD t ROM 10 AATERIAL, EM PTA CEMF.N METHOD&AMOUN'
Non-Water Supply Well: Z, ft. a 2- CI ",/, ..a*,, 7t"/-6?rs-' - 1., 571) I tO>
0Morlitoting CIRecovery ft. ft.
Injection Well:
ft. ft.
°Aquifer Recharge DGroundwater Reinediation
IS.SAND/GRAVEL.PACK(If applicable)
0Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENTpfETHOD
DAquifer Test DStormwater Drainage z, ft. :ii ft.,ezz-e /4-
C3Experimental Technology DSubsidence Control ft. ri.
0Geothennal(Closed Loop) atracer 20.DRILLING LOG(attach additional Owen If necessary)
team to DES RIPTION(osier,hardness.sollirock Nne,min allt.act
DGeothemial(lleating/Cooling Return) 00ther(explain under#2l Remarks) ft' 4/40 ft
4.Dote Well(s)Completed:.2/2 0 9 Well 104 ft, ft.
5a.Well Location: ft. /.7e)n.
4 ,i,yde,.... .......
1 / i du
, 7ove t I inikifz.12_ ,ft. ft. ... ........, _
. . „ . ..
FacilitylO*r Name Fjcility 11)4(if applicable) ft. ft. 4.-.-6,...c„„.4,i,,,,,„.4 i ii 4--„i
-'-' /Y 14-ii e- a-, lx.-,./4/, it--L2s15 -2,0
.../4// ft. ft. __
MAR 9, 0 202,t
Physics ddress,City,sad Zip ft• R.
i e*--0,. o ,,. A, --) 21.REMARKS
County Parcel Identification No (PIN)
Sh,Latitude and longitude in degrees/minutes/seconds or decimal degrees: •-
(if well field,one laulong is suffasep) 22.Certificado ,S1111111111 "7" -
3 51 2'3 r /P N ? 2 j .24/ / ''7. 4
W C., 41 -a•d0.°. /;b#,/,7/
Si.-1 c 07 ratified Cont ate 7 '
6.Is(are)the well(s) -ermanen_c) or 0Tempora
0 •wiling this form Ilk ehTeertity that the well(s)was(were)constructed in accordance with
7.1s this a repair to an existing well: lieces o o ,' 5A NCAC 02C.0100 or LIA Nat C 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well ci.nstructi n information jy'April..'tonne of the of this record has been provided to the xdl owner.
repair under t$21 remarks section or on the bark of this form
23.Site diagram or additional well details:
S.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
constniction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).N'ou may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / €-‘. '361e 00 For multipleSubmit this GW-1 within 30 days of well completion per the following:
wells list all depths if different(example-34000'and 2@l00)
10.Static water level below top of casing: / /1,- 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level it above castug,use '
11.Borehole diameter: ip (in.) 24b. For Infection Wells:Copy to DWR,Underground Injection Control(1UC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i'Vl L.11,1 !'s-'/L4 1.•t.i 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(IC,auger,rotary,cable,direct push,etc.f county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GAD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
131,Yield(gprit) 52) _. Method of test: A it-
13b.Disinfection type: /4 I/ Amount:6;') 0'2...
Form G'W'-1 North Carolina Depanmcnt of FAivironmental Quality-Division of Water Resources Revised 6-6-20111
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