GW1--02541_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Info ation: '
��' Avfr, / erb,-..-,11�.� IIII/1 lic.,e, i4t`WATER ZONES
WellFROM TO DESCRIPTION
ContractorNami
. /©b ft. ft.
2_c�3 ��o ft ft.
NC Well Contractor Certification Number
/)
// J • 15:OUTER CASING'(for:multi-cased wells)OR LINER:(f ap ilcable):'.t ::':"
'OK i11J/15 wel 1 ,ac//41 e,,k FROhf TO DIAMETER THICKNESS MATE
Y an ComP Name 4,/pi!. ‘o ft 6�� in. Z /
'16:INNER.CASING:ORTUBING,(geothecinal closed=loop) '-- -. =-
2.Well Construction-Permit#: ' 2--3 I 2.5* Z- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construeliot permits(i.e.U/C,County.State,Variance,etc.) ft. ft j in.
3.Well Use(cheek well use): ft. ft in.
Water Supply Well:
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heatiug/Cooling Supply) ).esidential Water Supply(single) ft ft. i'n. .
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL �EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: O ft. t'f() ftCADT:Intil j.j -POU-re.,/
❑Monitoring ❑Recovery ft. ft. t�/I lfklt TC C,C�
Injection Well: ft. R.
❑Aquifer Recharge : ❑Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)='r.: ' - ' -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer `120.DRILLING-LOG(attach additional sheets if necessary). . " _: :=
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft. 10 ft. c/
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4.Date Well(s)Completed:2 --.46-- '',Well ID# Z.Q ft *'. ft. lea 4 L�e.
5a.Well Location: ��J 1 - 60 ft' 44.e �lu '/e.- •
/ /J 60 ft 360 11* n/“G .k-k.
Facility/Owner Name Facility ID#(if applicable)ic ft. ft.
-7 S �t'3 r CJiC•11''lie.), �C _ .._...... ... •"
$hysical Address,City,and Zip // >' r� ft ft. L• �.. 'c� .i. 'V' a....:..,i
�Y f 'DD� 21:REMARICS: r::- _ ..r�-tPil "L i —02jr _ .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: [ .` L.,J
(if well field,one latlllo �/O
ong is sufficient) / 22.Certification:
,
3 /' g/�-/ Z 6 N 6 z6®'10 w 26-
zeII
6.Is(are)the well(s): I�Permanent or ❑Temporary ignature of Certified Well Contractor Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or , No 15A NCAC 02C.0100 or 15A NOW 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 rentalk 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: 3 60 (t) 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 a 100')
Z 24a. For All Wells: Original farm to Division of Water Resources (DWR),
10.Static water level below top of casing: -' (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If waler level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 /gl ,,I cl(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 41✓ ✓�1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) (j county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
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9T
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) j/ J Method of test: i so"13b.Disinfection type: r1�/
l Amount: 3 0-&