GW1--02576_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: //7
Ke.,I l/-i In /6 0 l /- / ii✓1 G`✓+ Ac.'
e.
Well Contractor Name _ FROM TO DESCRIPTION
%� ft.' ft.
NC Well Contractor Certification Number /] // 15:.OUTER CASING"(for multi aced wells)'OR LINER(dap licable)'::.': .
f� Z. /4/1 /L,s we•J� //%1'f in.„? FROM Ye.
TO It DIAMETER in THICKNESS MATERIAL
Company Name /J C�J'l 7'//Z CIO �Ys' ,/Z 5" /LI G
I q / 16:INNER:CASING OR-TUBING(geothermal closed loop) .: ``.'i :-i .
2.Well Construction Permit#: ' /00 I /6 q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction periluits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. .rt. in.
Water Supply Well•
.FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) FtiResidential Water Supply(single) ft. . ft, in. '
❑Industrial/Commercial ['Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL o EMPLACEMENT METHOD&AMOUNT T
Non-Water Supply Well: b ft. a° ft. 'Cienu r.v.Sr< f"`'-e c-e
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 ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
0 Geothermal(Closed Loop) OTracer -20.DRILLING LOG(attach additionabsheets if necessary) .''`:'- "•
FROM TO DES�RIPTIO�lor.hardness.soil/rock type.grain size.etc.)
OGeothermal(Heating/Cooling Return)) ❑Other(explain under#21 Remarks) 0 ft. ZO ft. ,CC/ 4s._A
4.Date Well(s)Completed: )-Q0`y)—1 Well ID# 7,451 ft. SJ ft. SaoSaoDyi//,►‘ �J J
Sa.Well Location: SJl ft- !d f- SS�ea'e//77 /lire .
ericm . a A/r,TaL® airuittvutz)(1c,r-/0 it
ft. dh 6:ic ►7 ` K
Facility/Owner Name
_ I L r (._ /FacilitylD#(ifap/pllicablle) ft. ft.
//7> G•t'e -/- e ke.//•-4 /d f7 �J7 Z4 ft ft. -._.r.< r. -
Ge P73111 -"•
d
lihysical Address,City,and Zip ft. ft. .•i.:,��. L'.s i`. .V
,,� •21.REMARICS:,. `-': ;•:":::'.: Si'._":.' .. ,. .• ....- -. . - -
ie.
ofc,
oz.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;,,;-----
(if well field,one lat/longis sufficient) V{f a u;,z:':r01
t22.Certification: r
3 3TC) N 'c). S'Z-! 6�� w _�.�/���d, _a l -Q`1
6.Is(are)the well(s):ji'ermanent or ❑Temporary Signature of�erhfied Well 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 JNo 1 SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out know,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 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
t
9.Total well depth below land surface: (OM (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii fermi(example-3(a200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: gC) (1t) Information Processing Unit,1617 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: 6 flfl (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: F'c\se— 4 " 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
•
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
i
13a.Yield(gpm) � Permit Program,1611 MSC,Raleigh,NC 27699-1611
/� .`Method of test: iT 1e
13b.Disinfection type: /'`f/ice/ Amount: 3 Ai./