GW1--02386_Well Construction - GW1_20240423

WELL CONSTRUCTION RECORD(CW-I) For lotetnal Ilse t mly.
I.\Yell Contractor Information: "`' 3l /
Nick Young _ 1d.WAT►.R7.ONV.3 I
1\'ell noon.tor _ FROM Mt I Div[SIPHON
4605-A 1r~ .,?,�{ " l C�
ft. m.
\v.Well oniraMr Cr:vliention Nnmbrt
IS.OU' R G(SFN/_(far multi., d wel1q R IJF WW Of•pplioble)
N.W- Poole Well and Pump Co. FROM , TO FRAMIIFR IIIICKNI2t1 MAAIIR/AL
Compnav Name ._ f , it4 ft. 6? In. J f(i vt et ✓
1 _16.INNKRCASING OR_T_UURING(Srathrrmal cimlyd-lamp)
2.Well Construction PCniltt 9: fs is,]- ('I-)1 0` . FROM TO -mimes ER IIIICKNEA9 MAT TRW.
ran air apnccahlr'a-!i conrt-,orlon pernrrta(i.e.WC,County:State.Variance.etc I IL IL in
3.Well Use(check well use): rt. D. is
Water Supply Well: IT.SCREEN
FROM TO IRAMETER SLOT 917.E T111[KN1249 -MA TF.RIAL
;:.\gtiallnlrai ❑MunicipalTublic 0. it be
❑(tivthennal(Heating Cooling Supply) (CiResidential Water Supply(single) R n. In
❑industrial/Commercial °Residential Water Supply(shared)
tali GROUT
'Dlmgation ❑Wells'100,000GPD FROM TO MATERIAL ' EMPIACEMESTMET/I00&AMOh.T
Non-Water Supply Well: C R ,AU 2 "Fo,\}cv-.k- ,y '
M.nitonng °Rixovery R ft. l
injection Well:
OAquife Recharge it R
❑Groundwntcr Renediaiirn
❑:\quite Storage and Rixov t9.SAND/GRAVEl.PACK(UappIable)
�' °Salinity Barrier FROM TO MATERIAL. EMPLACF.MFTT ME TROD
❑Aquifer Tat ❑Stormivatet Drainage n. R. -
°Experimental Technology °Subsidence Control 1L n. -
°Gonthe mal(Closed Loop) °Tracy 20.DRILLING LOG(attach additional theca If nearury)
°Geothermal(Nearing Cooling Return) ❑Other(etpilain under 421 Rernarlcs) FROM TO DESCRIPTION(color natant„mil/rock type,gala tlre,etc)
0) R 3, R Tcp. So.1 _
4.}late\%'ell(s)Completed: 1 i- 3-c-2T3 Well IN ,). R i L/0 R ( 1
Sa.Well Location: . I'l U R O.(oS-"• t ! ie1 i k .1. +"
T7r\,1-1-. Sint 4i) _
Facility/Owner Name Facility ma(if applicable) R o.
APR 2 .• 20Z4
�7 I Cam1--,_,)
- / R R
�'l ZL7 v!'t�%C Car 1 L�i J.t'i ') Y�Q
Physical Address,City,and Zip f 1 III ft. A. : .�...,. .-I
1.'", - h 21.REMARKS ...;-.1
C.i'3,
County Parcel Identificst:on No.(PIN) Used steel hardened drive shoe
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long a sullicirnt)
22.Certification:
35. (93 N - -7$.` 2(4 2-3
W
t Is(are)the walks): �Petmanent or ❑Temporan Signal c of . ell Contra r Date
By signing this form I hereby ee ify dmt the woll(s)war(C)--were)constructed in aecordnnte wren
7.is this a repair to an existing well: ❑Yes or O No /SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a caps
if tie'is a,.pars fill out kwwn well construction information and explain the nature of the of this record has been provided to the well owner.
repair W.I.(e 21 remarks section or on the back of this form
23.Site diagram or additional well details:
&For Geoprobc/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 needol. Indicate TOTAL,NUMBER of%tills (add See Over'in Remarks Box).You may else attach additional pages if necessary
d llul: r� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �I Cv n_ (n)
For multiple wells nut all deFthr if aifferent(example-3 w20('and 2(@a/00') Submit this GW-1 within 30 days of well compictlon per the follow ir1�:
24a. For All Wells: Original form to Division of Water Resources iD`.1I'�.
10.Static water level below top of casing: �- D (a-) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
r1. is wear leveI choir casing we"-,
] Borehole Wormier: On)tin) 246.For Injection Wells:Copy to DWR,Underground injsxtion Control(ILCs
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
method:12.Well construction method: 24c.For Water Supple and Open-Loop Geothermal Return Welts:Coe;bathe
.e.ages,^•Hairy,csble,duce!pick,,cis) county environmental(iailth department of the county while insulted
FOR WATER SLPPI,Y WELLS ONLY: 24d.For Water Wells pruduclns, over 100,000 GPI):Cops to[-Aka. ",A
Blow Permit Program.1611 MSC,Raleigh,NC 276i99-}6l 1
i 13a.Yield(xpnlh it r, Method of test:
1136.Disinfection type:HTH Amount:
l,.irn.'S'd'-1 :lulu;Cott/dug Depatuncnt of fnvuonmrntal Quality-Division of FY.iter t(csuurees 't:...rd:.¢-:5a