GW1--02531_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
v 1 eFFrev (-cat" -', 1/C.�, .eg'el 374c/f:o - la:'WATER ZONES a :
Well Contractor Nam FROM TO DESCRIPTION
� ft. ft. 80� t 2n�a yoJ a gS
.
0 ft: ft.
NC Well Contractor Certification Number
/ M / L� It/ u� 115..OUTER'CASING'(for multi-cased
wellsyOR LINER(flap pllllicable)-=:': • ,-
[/r (�• 1 t l GfiL//' S La-el/ IVrrr ATERIAL
�G G�i� 7� /FROf it
11 Li
ft (J '8 DIAMETER in. THICKNESS.015 I MP C
Company Name l
Co :16:INNER:CASING-ORTUBING:(geotherinalclosed-loop)T- :
2.Well Construction Permit#: t.3 Ili y l0 FROM TO DIAMETER THICKNESS MATERIAL
•
•List all applicable well Uonsiruction permits(i.e.UIG County.State,Variance,etc.) ft. ft. in.
.. 3.Well Use(check well use): ft. ft in.
Water Supply Well:
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public it. ft in.•
OGeothermal(Heating/Cooling Supply) teltesidential Water Supply(single) ft ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000GPD . FROM TO a MATERIALS EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. el v ft. dg.ru et.t& pd•t�
OMonitoring ❑Recovery ft. ft N
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19'SAND/GRAVEGPACK(if applicable).;:: •- "::
❑A uifer Storage and Recovery ❑Salmit Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :20.DRILLING-LOG:(attach additional sheets if necessary):.,::_ -. . -
FROM TO DESCRIPTION(color.hardness.son/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Returns) ❑^Other(explain under#21 Remarks) O ft. r 8 rt. ,� t/owG.(-y
4.Date Well(s)Completed: Y "'3 .'c2 ell ID# I ' ft. £& �ft. to ,S-f//�am t�
Sa.Well Location: .- Si fft' 3 OOft• pc.L,e , Gu
. ::ran c,Lon I'0,u)h ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�j/ C� /� p r f-
'!(0 O / -g / of7t'pl"f !\ d ft ft l 'E;.....'‘:,. 'L,.i +:" 2--,'�..
, Physical Address,City,and Zip I) I' n 2 e P`/ �r ft. ft. APR 2 6' 2024
' OL- L) - -VI 21:REMARKS: :: . .. ..
County Parcel Identification No.(PIN) lr' "'' `` ^.gr:.(c 'is
UV 04%JL.3LJV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long/is sufficient) 22.Certification: . •
31. £i'5oo( N $t7. Icil0:35(D. W II -3."02-LI
6.Is(are)the well(s): lji<manent or ❑Temporary r f Cent Well Contractor Date
/ By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ISO 154 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 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 Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: °o (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
, 10.Static water level below top of casing: _5 (ft)
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+" i
11.Borehole diameter: &%/' (in.)
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: !\D !-a r� 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 SUPPLY WELLS ONLY:
A24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Method of test: /T h✓' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /
'/
13b.Disinfection type: hL tT/ Amount:_3 lc'le4 Y-S