GW1--02532_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
je-C--clr UGIC. 1 01(tAiI h0::,c,60,r) 14:WATER"ZONES < : 1,' . ..
Well Contractor I i e • FROM TO DESCRIPTION
yle0aft i� is , �a�
NC Well Contractor Certification Number
*�(� 1 T1,, 155:OUTERCASINGG(for:multi=cased';wells)OR LINER(if aft licable) : ' ,
i •L• I 1 1 .U. I.I s �� I �r 1 I I,I j� '•J�1 1 G. FROM TO DIAMETER THICKNESS. RI MATERIAL.
t 1 I , ft. q 9 1 ft. + _(I in. "1 5 IP F P
Company Name ' � T �i \,Q � o)J •-i'V c�
r - 16:INNER:CASING:ORTUBING:(geothermalclosed=loop)
2.Well Construction Permit#: • C 3_ 3e�5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. -ft in.
17c'SCREEN:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public ft. ft i.in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) p, it. , In. ,
0 Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT :`
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: y� ft. tt
te -
OMonitoring ❑Recovery Ff ft. © it. n�ut,i•1-e our ent
Injection Well:
ft ft
['Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK(If applicable) ''.:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft '
OGeothermal(Closed Loop) ❑Tracer -220 DRILLING LOG(attach-additional'sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilrnck type,grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. 'l0 ft
4.Date Well(s)Completed:114:15-aLi Well ID# AOft. (�D ft (t.a_n -A I .6-oton 3 Dr
5a.Well Location: .° y© ft. q L B-3„-oU are I-bur_ &i'4-r;
'---beIci r_,4 ErV I n 1-17 Gcj) ft.
Facility/Own a`me Facility ID#(if appli le) ft. ft.
I 1 1 Iy ('.lb\US .1/kr. ft. b. �.;L .r.`11 a,_
Physical Address,City,and Zip /�I �1 p �}
Girl l Dr-) �l Jl�]- l l .l- ��� 21 REMARKS : H f R 4 t) 2024 ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ". t r wv
(if well field,( (� // r -one let/long is sufficient) 22.Certification:
(i
ail4' . 4 • y- 15-aoaL)
6.Is(are)the well(s): L9Permanent or ❑Temporary Ad Well Contractor Date
By signing thisform,Ihereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or P41Vo ISA NCAC 02C.0100 or ISA 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.
, repair under#21 remark section or on the back of this form. i•
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 (ft.) Submit this GW-1 within 30 days of well completion per the following:
' For multiple wells list all depths if different(example-3Q200'and 2©100)
' ` I 24a. For All Wells: Original{form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Limier level is above casing.use"+"
1,9 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole tiinmeter: 1(in.) program,1636 MSC,Raleigh,NC 37699-1636
12.Well construction method: O'1-aIl i trJ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health deplanment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produc'rntlover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 'I©�-�-, 1 Method of test: R I r Permit Program,1611 MSC,Ralf gh,NC 27699-1611
13b.Disinfection type: f— ' 1'1 Amount:_i h 1