GW1--02561_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • .
1. `Well Contractori Information- •
IGO.N.tir-)
[.had. n U1 f 115 3GGIc-sU\r‘ 14.WATER ZONES ' - . . ..
Well Contractor Name FROM TO DESCRIPTION
(j^ ft. ft.
2 O 1 1�a10 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased w G' ells)OR LINER(-dap licable
'` y\rs U\` I\ \ 1 \ N-A\1( 5
FROM TO D1AM R THICKNESS MATERIAL
Company_Name `)\ \ �) ` .-•�.1 ft. r:]5 ft. %_(e in. t r"1 s- v�c
�n 16.INNER:CAS CASING OK TUBIING(��g))eothermal'cloose&loop) ':_,- , . .
2.Well Construction Per)nit#: . ' ,c 1 (, i- (3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Conant'.State,Variance,etc.) ft. ft. is
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.
0 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. • •
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT-':.: , _. --
❑irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (, ft- '2-0 it. 13C146111 11,OJ`t—c-cl
❑Monitoring ❑Recovery R. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
:19:SAND/GRAVEL PACK(ifapplicable) ' '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control- ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG(attach additional sheets.if necessary):;.'.- '..i
FROM TO DESCRIPTION(color,hardness,soWrock type,grain size.eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. l o ft. � G\c /
4,Date We11(s)Completed: `Z�� �21L-I Well ID# Il b ft. 2 0 ft 5/•.e 11 f otr k
5a.Well Location: `,tt 26 it, 20 ft b\V.e 4a4d
L`<'nt4 -e Co1/4r\ ft. ft.
Facility/Owner Name Facility ID#(it-applicable) ft. ft. •
�y / -1 n, +'� -- ' ... .1 i,ice' �1-
Oi i41 Il rp 1`� ft f. {5 .�b�', ,.�...: :r
Physical Address,City,and Zip .�y I_ ft. ft. APR L U ZG24
6
County • Parcel Identification No.(PIN) tr,`,L,rT-•,. :.t i i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
'1G. , -±0`-‘6 e3 N eCA 2e2.--1 w 111-46"i
6.Is(are)the weli(s):pPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the wells)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or 0No 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 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: z 56 I (ft-) Submit this GW-1 within 30 days of well completion per the following;
For multiple wells list all depths ifdifferent(example-3 t@200'and 2©100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Z 0 1 (ft) • Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+' i
/ g 24b.For Injection Wells: Copy to DWR,Underground Injection Control(Il1C)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Or t r- C'y 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) qS r (� Method of test: ilk _�,_[ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1� 1 T l Amount: 1 t h 1