GW1--02558_Well Construction - GW1_20240426

WELL CONST'"UCTION RECORD(GW-1) For Internal Use Only: •
V
1.Well Contractor Information: / .
Te F�'r'e y �LC G!`�''€r-/ gf Ci.h Price t£? •14r-WATER ZONES :
Well Contractor Name ss FROM TO DESCRIPTION A
L�� ft., ft. 65 / 5) l isi l XJr
ft. ft.
NC Well Contractor Certification Number
15..OUTER CASING(fot multi-caseda wells
),OR LINER
INER.('dap licuble)R1 i,::'_ •• ---
TO ' DIAMETER THICKNESS `ATERIAL
Vv.. .i )�. // c `'vp/,/ Vt./If/r. 2/(l4 FROM
f ! It 11. fL � in. xt ® 1 ) ',
Company Name 16.INNER:CASING:ORTUBING(Reother"malclosed4o00'-- .-.
2:Well ConstructionPerMit#: - • 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): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) Cile:idential Water Supply(single) ft. fa in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) ..1�.
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑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
0 Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer :20:DRILLING LOG(attach:additional sheets if necessary),:•:'`- : -` '
FROM TO DESCRIPTION(color,hardness.soil/rock type.Crain size,etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ft. •I ft. e`/ S to I i e
4,Date Well �t�s)Completed: -/.' /ell ID# 0 ft. o2 I-yft- 7 Lu e 5 Lc�
5a.Well Location: t -" tr= y� ft. ?1 t�V G PI ✓t r.p
I = fL �C ft.
3e-ver1 gp v - _ �--._...,_•
-
Facility/Owner Name ifacility ID#(if applicable) ft. rt.
o 7. c 6 t eG t'i ✓e LEI.'C�y ft. ft.
Physical Address,City,and Zip r(� / ft. ft. 1 ,k
'.,, ! 1 O / APR 4
21 REMARIGS. k'1� �\ ,s'�'� r ii _ ..
57
County s Parcel Identification No.(PIN) t) . 2U24
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: lr.:.:n.:.i'r: P . dnic-12 Ur•:l
J S® L$ / NS V 0 3 97 6W -01 L
6.Is(are)the well(s): ermanent or ❑Temporary of tfied Well Contractor Date
/^ By signing this form,I hereby certify that the wells)leas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or dgNo 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.
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 GWil 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: pa t (ft.) Submit this GW-1 within 30 days of well completion per the following:
.For multiple wells list all depths if different(example-3Qa 200'an.2Q100)
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
ee„ If water level is above casing,use"T"
1 / 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
& �
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well'construction method: / 0a�!',/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
"• (i.e.auger,rotary,cable,direct push,etc.) cdfanty 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
r. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) '-� Method of test:
13b.Disinfection type: TT 77/ Amount:
3P/I`)-II"5