GW1--02530_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,
1.Wel Contractor Information:
• f cs -0, yY =14.WATER ZONES ;.':-'1 :' ;,'
Well Contractor Name r• FROM TO DESCRIPTION
ft. ft.
1433�e- .
ft. ft.
NC Well Contractor Certification Number
///�����^ 15:.OUTER CASING(for multi-cnscd`wells)OR LINER(if'ap'liceble)•"-'; :.
I y y , p 1 J06 I n,� 1 1/'' 11 FROM TO DIAMETER TRICKINESS hfA,TpER�[rAL
a 1 r /v�1` \J�+C/VVV��1 �/t C3ft. 4LI ft, 1 „ )% in. f�'Z,5 6 y c.
Company Name lV
7�`i 16.INNER.CASING:OR TUBING(geotherinatclosed=loop):: "=. r.< ':_:'
2.Well Construction Permit#: �.J) D. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County.State,Variance,etc.) 0 ft. 6s ft. in. ;Z>;J P y
3.Well Use(check well use): • ft. rt. 9 in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) iliftlesl ential Water Supply(single) ft. ft. in. •
0 Industrial/Commercial ❑Residential Water Supply(shared) 1>l.GROUT_"
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. bs- ft. ' 104 Nog.
JP
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑AquiferRecharge s ❑GroundwaterRemediation
19.SAND/GRAVEL PACK(if :...::' - .,
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft, ft.
OGeothermal(Closed Loop) ❑Tracer •20.DRILLING LOG(attach additional sheets if necessary) '= - .._ -.
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hanlness,somrock type,grain size,etc.)ft.
tt. ft.
4.Date Well(s)Completed: 11 fJ O?211 Well ID# rt. ft.
ft. ft. •
5a.Well Location: ;•�
Facility/OwnerQ�lity Name n I as acility ID#(if applicable) rt. ft. ; 'k�v i'
OV.fo Old 1 41()44 5 /2/ i ) h ip 1 V L Gat ft. ft. e l.•....,..••:..•. '''' .
J l� StiIJ� `� f�
Physical Address,City,and Zip ` / / ft. ft. APR �+ o L�124
vl►�) 0Z^ 1 11 -L 06 L 21:REMARICS: i,t:,
County Parcel Identification No.(PIN) tP'•' - r.,0 •".1 I.:i + J M
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificati
35. O1')3Ze N -,SUa 362.3)<- w g1?z1
Signature o ertified Well Contrec oc, Date
6.IS(are)the well(s): a "-nent or ❑T
By signing this form,I rebv HI&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: es or 121No 15A NCAC 02C.010 SA NCAC 02C.0200 Well Construction Standards and that a copy
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.
I repair under#21 remark.section or on the back 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
construction,only 1 rW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 ) (ft.)
For multiple wells list all depths ifd different(example-3@200'and 2©100� Submit this GW-1 within 30 days of well completion per the following;
t 5^ ( 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: � ,.
If water level is above casing.use"+" L,If Processing Unit,1617 MSC,Raleigh,NC 27699 1617
11.Borehole diameter: fa . L. (in.) 24b.For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: -,•1 C 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLYY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA/13a.Yield(gpm) 2 Method of test: i r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /1/ N Amount: g Oa