GW1--02550_Well Construction - GW1_20240426

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WELL C 1nNSTRUCTIION RECORD(GW-1) For Internal Use Only: i '
1.Well Contractor Information:
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e(Frey etc-c�'er- �6C z...;rl C acI/
fSen '14.WATER.ZONES•::'- k .,- .
Well Contractor Name e FROM TO DESCRIPTION G C
ft. ft.
NC Well Contractor Certification Number
G.
/y� y,( 15::OUTERCASING:(for multi=cased we110:OR LINER'(if ap licable)' '7a';;:_,.'::- -
FROVr G. /t t.z-di S welt �/'t ct ,3„, z./ife. _J 1t ft. I ft.TO DIAMETER
in. /taSSS MATERIAL P�
Company Name •
T I
.'16:INNER.CASINGORTUDING(geothermal-closed=loop):-,: ,:.:• ':-a '
• 2.Well Construction'Pernitit#: a3- 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): • rL rt. in.
Water Supply Well: I7 sCREEN_ ..'
FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mujpiipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a 0 ft.
75siana,i:za. p o k r e.d
❑Monitoring ❑Recovery ft. It.
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 ❑StormwaterDrainage n• ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additionalsheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotUrack type,grain size,etc.)
0 ft. 7 0 ft. pew-Cr�,� , ,GL ,
4.Date Well(s)Completed:` `--". " o?71Well ID# e2. 0 ft. y 0 ft , ,..e."�.w c
5a.Well Location: s,1 r y0 ft. e? / ft. 2 e 4- D, w n 5 Le Z
V I\U, 9! fL 3 a F9 Lec e G.+a.
Facility/Owner Name Facility ID#(if ap li able) ft. R
$S l.i o L 0 ti e Rd ft. ft.
L.t/a.X a u� M D!1 fo __ �a 1. y+.
Pltysical Address,City,and Zip ft. ft `
CJDqn {`O 21REMARCS: :'_ . . - -- AV .! ,. . ; "R � ry •_ -
bc,n td n
County Parcel Identification No.(PIN) •,--.-.••r•.::tt'�a:k,::g
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: '
3 L1. 9 0 86 6 N So. 17.3 o''7/ w -/� q �q
6.Is(are)the well(s): ermanent or ❑Temporary
Sia�t Cell Contractor �es/ /
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 ONO'''. 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.
t repair under#21 remar/a 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
9.Total well depth below land surface: .3 0 0 (ft.) 1
For multiple wells list all depths ifd different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
0 24a. For All Wells: Original form to Division of'Water Resources (DWR),
10.Static water level below top of casing: at') Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" g +
//__ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: C� S /� 1(in.) Program, 1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: fit;/'a./ t/ 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: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) if 0 Method of test: /7/•/' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: hL T f7- Amount: a p t n-Es