GW1--02546_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: j
1
Z FFr`'e t -2-C4Rev r /Ga aj Tee C/r5 o r) -14:MATERZONES _ .. ._. .'
• Well Contractor Name FROM TO +D�ESCCRIPTION p
-I,�ODo2 ft., fr.
9 (J O
tt.• ft.
NC Well Contractor Certification Number .'15.:OUTERCASING(for multi-cased wells)ORLINER(iif'ap'livable)-.•.• •
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T. L. / /// e// ,2,C;ii/ /1 /11c. FROM TO DIAMETER THICKNESS 1 MATERIAL
Company Name S 4_ / ft. LI& It. (o '//tl C in. . /42 p vc
.i 16 INNER:CA/SING:OR TUBING:(geOothermalclosed=loop):`...'1*. < '':: •` .'.
2.Well Construction Permit#: • A LI FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construtlion permits(i.e.UIC,County.Stale,Variance,etc.) ft. ft. in.
,: 3.Well Use(check Well use): ft. ft. in.
Water Supply Well: l7:SCREEN.'
•FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. . ft. in.
❑Geothermal(Heating/Cooling Supply) Egte.sidential Water Supply(single) ft. ft. tn. .
❑lndustrial/Commercial ❑Residential Water Supply(shared)
::'18:GROUT:.,.. , _._.. . :. ,,. __•..:.:. ...:...:.... . •, •: -
❑Irrigation ❑Wells>100,000 GPD ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a,0 RVorfrpte. PO-uie
❑Monitoring ❑Recovery ft. ft.
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 OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :20:DRILLING LOG(attach:udditionalsheett if necessary)-;': :.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,soIDroek type grain size.etc.)
' I 0 rt. a. o ft. fled C
4.Date Well(s)Completed:3 1 II"t� 11 Well ID# c o ft' l� ft JJ z...e_ -5 j�,8ce.--n _51-one
5a.Well Location: !•/ ft. o f. L44-e S-eet
", f. ft.
+rr. Marrs r ,(op
Facility/Owner Name Facility ID#(if applicable) ft. R'
3 7/02 Red Fox "fret;c. ft ft. r-. �.r iT. ;..r
Physical Address,City,^and Zip ^r^ (� / Q ft. ft.
itLi l(rbl 1 • \ 1V0 6�� 13 21.REMARKS;: :•.'. .-::.:.::,- .... ,:'A:P17 yi ,: 'iD2%1t'
County Parcel Identification No.(PIN)
ifr::.iirA.t', s-- .,7.--- ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35• o s g N �30. 7,,11.0 o02- w -s il ? _ •
3- / -a
6.Is(are)the well(s): Qrmanent or ❑Temporary S na of Cgkf ed Well Contractor Date
f 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 Pl 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 h formation 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. 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: 0 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: (� 'Z n (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii different(example-3@200'and 2@100')
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
If water level is above casing,use"+"
R' (in.) 24b.For Injection Wells:Copy:
11.Borehole diameter: L9 to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 110 71..a Y I 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: 1
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test: /�
13b.Disinfection type: T/+ Amount: !),n S i