GW1--02534_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I '
1.Well Contractor Information:
F--I'eJ/ �rcc/feY i !Q.v,.el 3—artc%,g`on ,>.4:�wATER ZONES.<: i_ .-. .;.
Well Contractor Nante FROM TO DESCRIPTION
y�Da ftft. 1. q� I ID ,� l b
. ft
NC Well Contractor Certification Number 15,:OUTERCASING4formniti-cased wells)OR LINER(ifilo Iicable)
M TO DIAMETER THICKNESS MATERIAL
9? . m ��;s wee r /'rc/,r/ICy .G'/i/C. FROM
ft �58 ft Co!' to .as Pit
Company Name `16'INNER:CASING OR-TUBING:(geotherinefelesed=loop)
2.Well Construction-Permit#: •t;t 3 3 S/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perinits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
Y• Water Supply Well:
—^ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Uawgricultural OMunicipal/Public ft. it. ;in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) _,
❑irrigation' ❑Wells>100,000 GPD FROM TO MATERIyALL ,,� EMPLACEMENT METHOD
&AMOUNT
Non-Water Supply Well: o ft a 0 ft. `9514 �JyLGl.E P ,p/
❑Monitoring ORecovery ft. ft. ,
Injection Well:
ft. ft. •
❑Aquifer Recharge ❑Groundwater Remediation
=19t.SAND/GRAVELPACIC(if applicable) ': -
• DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRIIL'INGLOG'(attach'additional sheets`ifnecessary)
OGeothermal(HeatingCooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness sowrocktype eraln size etc.)
L d ft a O ft. R,ed1 Cola_�
4.Date Well(s)Completed:i /�7 ` '/Well ID# '1 p ft (-/ 0d ft 5m d 5�n' 'B e ,Jit
5a.Well Location: ,.-•b, t o ft. SO p. r'Ot vl) /,3e4(' .s/„.. .
Richard /.eR.„1-- Jig ft a47/1,`- YYL4,P G..i-.-1.
Facility/Owner Name
c Facility JD#(if applicable) It
,.,: Physical Address,City,arid Zip It. ft. C. ' • '- ' an r" '
an I'1 t on O(�"O zl►a-age 7 "21;REMARKS. i.
APR L6 c0211
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: IN-0::. , n. 5*
(if well field,one Iat/long is sufficient) 22.Certification: 4:'t..,:i-'0
3S, 0a3 ) '7 N 8 ). 7o /5/ w y-/6- a2-/
•6.Is(are)the well(s): �manent or ❑Temporary a of ed Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ElYes or ditIN--.4c ISA NCAC 02C.0100 or 1SA 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 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: C) ^^ LID 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: of l v (ft') Submit this GW-1 within 30 d days of well completion per the following:
For multiple wells list all depths if dii ferent(example-3@200'and 21g700) t
, ` �/ 24a. For All Wells: Original'fform to Division of Water Resources (DWR),
10.Static water level below top of casing: - / v (ft') Information Processing Unit,1617:MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"" _ I
11.Borehole diti<ineter: T�$ (in,) 24b.For Injection Wells:Copy'ta DWR,Underground Injection Control(IUC)
/� 1 Program,1636 MSC,Raleigh,NC 27699-1636 '
12.Well construction method: %�D T�.r r,/ 24c.For Water Supply and Op n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb,'!.) / county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: _. 24d,For Water Wells producing g over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) \d Method of test / r
Permit Program,1611 MSC,Raleigh,NC 27699-16i I
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13b.Disinfection type:H j # Amount: .:3/2I r) izr