GW1--02551_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(OW-1) For Internal Use Only: .
1.�Welll�l jjContractor Informatin: ,h
N:.C!1L 1�^% Qi I . (GVAX.1 51'1 ' J 0 M1Se 14:`WATER ZONES :::.
Well Contractor Name FROM TO DESCRIPTION
• ft, ft.
NC Well Contractor Certification Number+�� 1 r 15..`OUTER CASING(for multi-cased wellsyOR LINER(if ap licable):.,
AA� ok1k W�i\1 b� t it ins ATERIAL
4,lFROt ft. /4Q� ft. 6P Rin. Ti (2.% �RIMNESS htP ,
Company Name _1 C► G.
16.INNER.CASING:OR TUBING(geothermal closed-loopy -; , _-=`
2.Well ConstructionPerinit#: � I k-k 2... FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft, ft. in.
"t 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(Heating/Cooling Supply) gResidential Water Supply(single) ft, ft, in. •
❑industrial/Commercial ❑Residential Water Supply(shared)
�.liI.GROUT ;•-.;- ..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL , EMPLACEMENTM OD&AMOUNT
Non-Water Supply Well: 0 R. 20 ft, ,��I1 `l
OMonitoring ❑Recovery ft. ft. 1s 16'i+
Injection Well:
• ft. ft. ,
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)` :' -'
❑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 .20.DRILLING LOG(attach:additional sheets ifnecessary)..::.---_'. :;.. -: :-
FROM TO DESCRIPTION(color,hardness,soWrock type,groin size,etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft. f 0 ft, b rsO cJY1 - cy
4.Date Well(s)Completed: 12 F1244 Well ID# /b H. z6 ft. <.s in� S i ;.`��
5a.Well Location: `►� 2�y ft. �j e9 it. b‘�� `�
t ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft' t4 T --_
it. ft. k, •� `: .p it_:,i. i?
:3264 f�w1 2.05
Physical Address,City,and Zip
ft. ft. AQ R 2 i; 7024
OFNion
27r'REMARI(S:
County Parcel Identification No.(PIN) .. ." - '7)-^gr• t �r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ®� 22.Certification:
t
SG a®61 05 . N C.9O n ‘a lac i3 W lie/ � vv' A�r6e. " 4..1 ' 12'12 24
6.Is(are)the well(s): {Permanent or ❑Temporary Signature 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: DYes or &No 1SA 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 mud 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: S 50 s (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 2Q100'
t ' 0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: S 0 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 2 t,
11.Borehole diameter: $ (in.)
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
qq � Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: '/-Y 1 r- f 6 T-V • 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: !
13b.Disinfection type: 'Wf fj{ 1T• Amount: 1 ?WA