GW1--02569_Well Construction - GW1_20240426

. WELL CONSTRUCT}IONN RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: �+� .� /
• TerFr'el 1u.G/'I.9 r /ad./ ) �/ ct-y' e2/') .4:`WATERZONES : .
Well Contractor Name FROM TO DESCRIPTION
�/ �� ft. ft. '78Jwoof IA !/a Mo
ft.' ft.
NC Well Contractor Certification Number
Gyp .15..OUTER CASSING'(for{multi-cased'.wells)'OR LINER(nip.ltceble).. : i.
L. Gfif'tr S cve�� �!'t Ll!/1GL 7iiC FRO3/I ft. T, 9 It. I D DIAMETER in. .25ESS 1 MATERIAL
Company Name see)/ r 16:INNER.CASING:OR-TUBING:(gaother►nalelosed-lbop)" .'
2.Well Construction Permit#: • 3 0 v v e)a FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable well constntcflon permits(i.e.URC,County.State,Variance,etc.) ._f-,I/ ft. t71 ft. ii in. C Gi 0 lot/
▪ 3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN <.. r
FROM' TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) L�Cesidential Water Supply(single) ft ft. in.
❑IndustrialCommercial ❑Residential Water Supply(shared) ;18:GROUT .
❑irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft a Oft- .}-. pm ee.tf Q.0
OMonitoring ❑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
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
0 Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary):.,-.- : . . .
FROM TO DESCRIPTION(colon hardness,soll/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D rt. G 0 ft. /t- C
4.Date Well(s)Completed:3 --` Y_ Well ID# (j b ft '7 0 t. Vzte e (' /gfe.cv JAoiie
Sa. ell Loca' n: . ° 7 q ft. a OOf- G `ec e
-►- flu
�E--F-P_. -(1
cL�;-xklc-GC ft ft.
Facility/Owner Name / L Facility ID#(if applicable) ft. ft.
/50
Plsysic ddress,City,and Zips /1 ft Sr. I .�• �F ' .i`S a' 3.,� y)
s ` `� , \ai- SS O / 1(O 27:'REIVIARIGS; ::r..:. :::: :. - APR 1+ V L 4
Co y OW Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I r :"H ' 7)"c"""' ) 1'./''
(if well field,one lat/longIL
is sufficient) . -� r� 22.Certification: ia't~ '.i 300
3 5a t!O(P o 66 N 66. Os o 3 W - L1/
6.Is(are)the well(s): permanent or ❑Temporary Si iue Ceni Well Contractor 'bate O�
By signing this fonts,I hereby certffy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19Ko ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repaii fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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 O-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: eQ D v (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if diferent(exanple-3@200'and 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
If water level is above casing,use"+"
11.Borehole diameter: G/5 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Q / Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: l D 1c6r7 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 0 Method of test: 111w I
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H 7771 - Amount: 3 f/h-I-5-