GW1--02583_Well Construction - GW1_20240426

WELL'CONSTRUCTION RECORD(GW4) • For Internal Use Only: '
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1.Well Contractor Information:
• CA artot y rti/1f'S ./Te Fire 7 i cAe r 14rwATERZONES
Well Contractor Name V u.t,j yi ��C if JD'I FROM ft. TO• ft' 77oNPTI 4 D
an-7)9 o ��SJ aso/✓
ft: ft. ' J
NC Well Contactor Certification Number •15...OUTER CASINGG'(for multi-cased:wells)`OR LINER(if ap ticable).
X L. // ue `/ S Wei/ r T r/ (('/I 1, ,2flic DIAMETEERIAL
- / ft.FROM T O LJ ft R in. THICKNESS MAT C
Company Name / $ (idsr
c';y [/�/� P ..165INNER-CASING ORTUBING(geotherivatclosed-loop) . .
2.Well Construction Permit#•(a!t � L Vim/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perirrits(i.e.UIC,County.State,Variance.etc.) ft. ft. in.
.. 3.Well Use(check well use): ft. ft in.
Water Supply Well: t7scREEN ..
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) {idential Water Supply(single) ft. ft in. •
❑Industrial/Commercial • ❑Residential Water Supply(shared) ..18 GROUT-
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. A 0 it. 2enO J p�`3e
❑Monitoring ❑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 OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ':20.DRILLING-LOG:(attach additional sheets.if necessary),.. .. . . . _.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,bardaess soi/roek type groin size ere)
l o ft. qS ft. �� �.la�
4.Date Well(s)Completed `l. Well ID# 4/3—ft &g i 2364.e 6. �,
5 Well Location: °&""k' _ / ft �J k ft. �V1N11 tJ J L,
� �c ft ft.
acility/Owner Name Facility ID#(if applicable) ft. ft.
/3 .. ' LN ft It r -
Physical Addre 'c&and Zi ft ft. t: ;�.' ,,.•L.. i jai`1. ;li�I
1 V , • .., .... .._
lA`'I J Q3 L/Q 3 2E-REMARKS . r n. . (
County Parcel Identification No.(PIN) r L' U L U z4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) • 22.Certif ation: DV;4.t1300
35e 53 o' 3 N Sol P7S S W (/ l 2aaLI
6.Is(are)the well(s): r�Permanent or ❑Temporary Signature of Certified 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 t3No 15A NCAC 02C.0100 or 15A 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 remar%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
9.Total well depth below land surface: (it.) Submit this GW-1 within 30 days of well completion per the following:
Far multiple wells list all depths if different(example-3®200' rtd.. TOO
10. water level below top of casing: (ft') 24a. For All Wells: Original form to Division of Water Resources (DWR),
a Ifwater10.Staticlevel is above casing,l top
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 4 /&' (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
1-� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 20 /u r 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) a J Method of test: iq it Imo' Permit Progtum,1611 MSC,Raleigh,NC 27699-1611
/T 13b.Disinfection type: / /7' Amount: 3 2%r)'Ll l-r