GW1--01984_Well Construction - GW1_20240401

er iEire:a:viv0if1Sue:ri(j1V.I.cLCUK.I)(GW-1) For Internal Use Only: I '
1.Wcl.Co�tractorInformation: ;
i��D 11/f# 1���1�r ,$44..J 14.WATER ZONES
WeltCotumelarName FROM TO DESCRIPTION '
c2 r3^ , .� tt. �P f •r., . G� /,�/�yfr/n�/ _
NC Well Contractor Certification Number ,/Ote7 f t• /72 - 'e eifr) ja,- `"7 ? �J �L S}
•r tS.'OUTER CASING(for multi cased'walls)OR LINER(trio'liable)'.� FRO.1T .TO .'DIAMETER THICKNESS- • MA
Company Name 1/z,,,st l{, ft. in. :�.d'I1'(J.. . //G ^--
16:INNER CASING OR TUBING closed-loop) ''
2.Well Construction Permit Its ' FROM - TO, - DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,Slale,:Variance,'etc.) ' ' ft. ft. - in.
3.Well Use(check well use): ft. tL ILL
Water Supply Well: 17.SCREEN -. a; _• - q, ,: ;y, , .:
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
°Agricultural ❑Municipal/Public it v ft. ft. IR.
/zo '
OGeothermal.(Aeating)CoolingSupply) ,Residential Water Supply(singte) � � ��
ft. ft. [n.
°Industrial/Commercial °Residential Water Supply(shared)
•,ri8:GROUT,.. .°= .`- ,•o .�.�- ....
°Irrigation ❑Wells>100,000 GPD most TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL ' ft.
E]Monitoting °Recovery- , a ft. fc �%31lyd-Cc. ��'f ����
Injection Well: R. It.
- -`
°Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL TACK(it mpprierible)' :� ':. '° `
°Aquifer Storage and Recovery __ ❑Salinity Barrier FROM TO -hATERIAL EMPLACEMENT ME HOD ---- --
°AquiferTest QStormwatcrDrainage la ft- /7p ft.,f':f ,./-//IL,. /�r^4.et /4ee/•iZP-- '?-
°Experimental Technology °Subsidence Control ft. ft.•
/
°Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) "Vr. ''r•
°Geothermal(Heating/Cooling Return) _ ❑Other(explain under fr'21 Remarks) FROM TO DESCRIPTION(color.hantnrn eo,urock t.Fe,grain size,etc 1
ft. h. - ,
4.Date Well(s)Completed:, Well IDtl ft ft.- '1 .
5a.Well Locatioon:: . . ft. it : 'h 4_;CL«y y f '6.)
($ htfr iiii!Url ' _ • H. ft:
,Facdn}; e/rNatne �-1 - ••-{ . ,FactliittyInfi(ifapppl`ic applicable) ft. ft
t o c .¢'4 1 JV.III � '. ,ff1/!I/tr''112r1d Lp✓i :7"L.l', ft ft. , . kP.a:ii';.rr'251 t•._ .'on. t..), ..
:••Physical AAddn ss,City;and Zip. `•-' - •- -. • . '.• ..;'- .... [s ii..0 c'L
/ / / rt.. ft
U i,-- c ,. . i - ' _. // 7, •
21:REMARKS 44 - , .a ,„l ,.
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt&cld,o e lat/long,is sufficient)
3 tell • • • '� i N 97 © � �
6 9 4W 22:Ccrtificatio
6.'Is(are)the weB(s):.J ermanent • or '°Temporary Si of Call tied Well Coo D te •
tgning this form,Thereby certilb that the wells)was(were)constructed In accordance with
7.Is this a repair to an existing well: -°Yes or 2tNo - ISA NCAC 02C.0100 or 15,1 NC-C 02C.0200 Well Construction Standards and that a copy
If this Ls a repair,,fill out known well construction information d explain the,nature of el.this rerord Itas been provided to the sell otmex
repair under#21.remarks section or an the back of this form.
23.Site dlagram'oradditional well details:
8.For GeoprobelDPT 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 r(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: p n f 24.SUBIIIITTAL INSTRUCTIONS
9.Total well depth below land surface C `t/ �v (ft) Submit this GW-I.within 30 days of well completion per'the following:Formuttiple wells list all depths((different(example-3(j200t�and 2®I00) -
10.Static water level below top of casing: / it.) tt 24a. For All Wells: Original form to Division of Water Resources -(DV/ ),
(
Ijunter level is abol a casing use Information Processing Unit,1617•MSC,Raleigh,NC 27699.1617 •
11:Roreitale'diameter /- r (in.) 24b.For Infection Wells:`Copy fo'D1VR,Undzrground Injection Control(IUC)(�� •
Pro m;:1636 MSC Raleigh NC'27699-1636 •
12:Well constructfon method:-_ 4'I t4d (t)'izl/r _ _ .. -. .
(i a'ougrr,iotary,cubic,diced push etc.)`• V 24e.For WaterSuPply and-Open-Loop Geothermal Return Wells:Copy to the'•
�' county environmental health department of the counfywhere installed
FOR WATER SUPPLY WELLS ONLY . •, l 3° r ,
• ., •, _ ,,, � 24d.For Water\Veiis producing oter I OQ.000 GPD:Copy to DWR,CCPCUA '
.` t Permit Program,1611-MSC,-Raleigh,NC 27699-1611
13a.Reid niti)-• .. Method of test.: . 111`L ,
13b.Disinfection type: +.14- •Amount tP:.1 0.r^•
Y' " . . ..• ..
•
:y"�^ V I.,.-, - - North Carolina Department ofEnvironmenlal Quality-Division of.W
i aterRcsourees Revised 6 6-2018
l:.. .