GW1--02562_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Info ation:
4-ert Li,-_ /--e- 4 / rfry feit- �er.-14:WATERZUNES t } .r .. ... . -
• Well Contractor Name < FROM TO DESCRIPTION
?�3 6 �, q�`e9 • . ft. ft. q 0 l 7 0
.ft, ft. !� 0
NC Well Contractor Certification Number
15.:OUTERCASING'(for mullieased.iveLlls)'OR LINER(if ap ltcable)•:;!:: .
�t, 1�r�1FROM TO DIAMETER THICKNESS 7 MA RIAL
�' Uv�l� Ajl,(yFROM y6' ft 64 in- seez 1 J�
Company Name
f y u�, 16.INNER.CASING:OR-TUBING:(geotherinalclosed=loop)r;''.-: '•i>::'-":*,. --•'- -
2.Well Construction Permit#: y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernzits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. -ft. in.
- Water Supply Well 17i SCREEN .;
•FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) fieesidential Water Supply(single) ft. ft. in, •
❑Industrial/Commercial ❑Residential Water Supply(shared)
:18:
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a 0 ft !J<2r
❑Monitoring ❑Recovery ft. ft. /` O tc
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
•:19:SAND/GRAVEL PACK(ifapplicable),"-:.''..-'_• .- •• .:---•.''•` •-. ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑AquiferTest ❑StormwaterDrainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 1:20.DRILLING-LOG'(attach additional sheets if necessary)',;.` .. .-
FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size.eta)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft. 45 ft.
C''j ct-'
4.Date Well(s)Completed:P. 'a L Well ID# /g ft 50 ft A/ p/
j s lG
5a.Well Location:
// J ;•J 30 It. 11S ft. 1 Id-lt-e .
ik, , ifs- ft. ti 0 oft- J '1 / I
�c.,�r� �•ts v
Facility/Ownner ame, ,cJ� Facility ID#(if applicable) ft ft. i ;t` :-i i' 't
Z4'G / &W Lbo,-a f. ft. C b• .�. 1....i: Iy9....,:Li
Rlysical Address,City,and Zipip L %/ � ft. ft. APR 2 U 2024
�l l / [1 21:REMARKS: - ,,
►re.- r.. .: . u�:;
County Parcel Identification No.(PIN) 4,.,��- -—
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
_3 Zg 3 N 'O, 3/755JS W '
6.Is(are)the well(s): ermanent or OTemporary
,,, ,,a_a r t 1___a i,,
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.wlth
7.Is this a repair to an existing well: ❑Yes or Piilflo 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
• If this Is a repair:fill out known well construction information and erplain 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 -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: Ile 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths((different(example-3(0200'and 2Q100')
24a. For All Wells: Original foim to Division of Water Resources (DWR),
10.Static water level below top of casing: 2 0 (ft) Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
If water level is above casing,usese"+
11.Borehole diameter: q 15 (in.) - 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
� f/ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: It 27 'rb %I/ 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) / 0 Method of test:
A t Permit Program,1611 MSC,Raleigh,NC 27699-1611
rr �_ 1
13b ..Disinfection type: / Amount: j ®/n 7-5