GW1--02570_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
J eFFr'e y Luc./f. r ,t/iY) tea•c/f
.SO YI 14 WATER ZONES =•_-: 1:' _•
Well Contractor Name FROM TO DESCRIPTION *
ft. - ft. r7 IF C,a G2,So
14 CO 0 • ft: ft. ! l j
NC Well Contractor Certification Number -
/L/, / u1n / G�7 15..OUTER'-CASING(for:multi-cased wells)OR•L1NER•(`f ap livable)-..:..':..
!� `. //t id/%S �[J e f( 7r'L I r H y Z/t/c FROM TO DIAMETER THICKNESS MATERIAL
Company Name o ! ft . �1 ft '/_VS in. a �5 01/C
(��-,- i�] :16:INNER;CASSIING'`OR-TUBIcNvG:(geotherinal closed=loop) /_
2.Well Construction Permit#: • IL " J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count:State,Variance,etc.) ft. ft. in.
3.Well Use(cheek well use): ft. ft in.
Y Water Supply Well:
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public�• ft, ft .in.
❑Geothermal(Heating/Cooling Supply) Etl sidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) a GROUT.
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a 0 ft. Ver itor1 i i.r io Q 1.4 r e a
OMonitoring ORecovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
'19:.SAND/GRAVEL PACK((if applicable)7:.- .-: .. - -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. It.
0 Geothermal(Closed Loop) ❑Tracer -20.DRILLING'LOG"(attach additional sheets if necessary):: ' ` . - •.
FROM TO DESCRIPTION(color,hardness,soNrock type.Frain size,etc.)
❑Geothermal(Heating/Coolingng Return) 1 ❑Other(explain under#21 Remarks) D ft. 5-0 ft. R� l
n.4.Date Well(s)Completed:✓ t✓a Well II)# c.5'O Et. to 2.,it. Cie 4, .S
k,2 ft. 3 .0- PCk,, G.�� •
5 Well Location: ` � ('I n
Facility/OwnerNaamme I Facility ID#(if applicable) ft R• I"' ;' rt-�•i ')
,26 O ft tt
�Ja.nS 6-ra5S,n� Die'
Phys' Address, tty,and Zip ('j/' /� ft. ft. APR L ��L4
lV� ��/1-Yr' UD� 21:RENIARKS
County Parcel Identification No.(PIN) lr"`%... - .,r,r,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
//one
/lnt/longg�is�suufficient) 22.Certification: �/•
33 . C�� i ! / N 3O: c'/1SD W ,nn - CXV'a 4
6.Is(are)the well(s): ( 1 manent or ❑Temporary �6m ofWell Contractor 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: ❑Yes or IlitIgo 154 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 erplain the nature of the of this record has been provided to the well owner.
, repair under#21 rentarltr 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: 0 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: lJ 0 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd different(example-3Q200'and 2Q100)
r24a. For All Wells: Original:form to Division of Water Resources (DWR),
a 10.Static water level below top of casing: (ft) Information Processing Unit,16'17 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 27699-1636
12.Well construction method: R O7Ct r>/ 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 '
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ` © v Method of test: in r I I'� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /4'IN Amount:_ 3/oi i 1-i