GW1--02555_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well ContractoLi
Inmotion:
[�.Q 0/to /l io on:am /14 a^ dc:. 14.iWATER ZONES
Well Contractor Name r FROM TO DESCRIPTION �L `n
Z036 Co O ft fd fr. f.e W(� /�'j-,��x J' (�/�
1 Oft. 3271
NC Well Contractor Certffication,Number 15:.OUTER C : for multi-cased wells)OR LINER(if'ap licable
616. A//1 S L.2 -/( %1 f ff n FROM TO DIAMETER THICKNESS MATERIAL
f
Company Name U //ZIL P 7 7 ft. 6A in. z /tiG
/ G •16:INNER.CASING:OR'TUBING.(geothermalclosed=loop); ` • .
2.Well Construction'Permit#: Jt '00 7 Z.. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) D ft. go ft. i L in. s C-t�pl q O pul C.)3.Well Use(check 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) j13Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT=
❑Irrigation ❑Wells>100,000 GPD ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
:Monitoring ORecovery ft. ft
Injection Well:
ft o R.
❑Aquifer 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) ❑Tracer 20.DRILLING-LOG(attach additional sheets if necessary) - .
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sontrock type,£rnln sloe.etc.)O R. ....2,,, fr. Cl � r
4.Date Well(s)Completed: 3~ - -VY'f Well ID# � fr
p . 35' ft 1..� 5 la V'e
Sa.Well Location: ;.� - -'S"ft. //7 ft A hie sl Ci fe •
A..---0:f'-- I P4-- - -- ‘7 ft- ..79.3 ft-
Facility/Owner Name 0 Facility ID#(if applicable) ft ft.
//59g Id! 4/ ft ft
Physical Address,City,and Zip �J ft ft. j 't, c.;... a..,r, ' t-.,,a-
57c1.�i /!.�/ -2 -4 y‘ 27.'REMARICS: rj(i.'SL i�?/i. ; .
County (J Parcel Identification No.(PIN) • ( ` `+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t :o.,: ,„
(if well field,one lat/long is sufficient) 22.Certification:
3S ziZiy2i0i p N ga /‘I/71 W e
6.Is(are)the well(s): ItiPermanent or OTemporary Signature of Certified We ontract r 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: :Wes or . No 15A NCAC 02C.0100 or 15A 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:
I repair under#21 rentarla section or our 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: ._ `0 (ft.)
For multiple wells list all depths ifd different(example-3@200'and 1Q100� Submit this GW-1 within 30 days of well completion per the following:
3 C 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (f0) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+•'
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (��� (in.) Program,1636 MSC,Raleigh,NC 27699-I636
12.Well construction method: /-a/ ' ' 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) 5'0 Method of test: /',- .L Permit Program,1611 MSC,Raleigh,NC 27699-1611
1311.Disinfection type: f7/��/ Amount: //K7 f