GW1--02584_Well Construction - GW1_20240426

WELL,CONSTRUCTION RECORD(OW-1) For Internal Use Only: •
1.Well Contractor Information:ft...t1jS 14.'WATER ZONES . 1
WellContractot-Name FROM TO DESCRIPTION
alaic ft., I ft.
(off ft: ft.
NC Well Contractor Certification� gg Number
ben ff 7..)-i't Iy�g/�� 15..OUTER CASING for multi-caacd.wells:OR LINER if a licablle).
(3(--mpa \f)�1 A..t `tIS ct L 1 1'`5 F3 ft. TO (ft DIAMETER METER in.) t a�S p� I V�
Company Name l/ t
ry -, I :16rINNER'CASING:ORTUBINGIgeothei•inuPclese&ldoW .:: ":r':
2.Well Construction tJ ✓OCk Permit#:j � "1()c�0?1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County.State,Variance,etc.) ft. ft. in.
t 3.Well Use(cheek well use): ft ft in.
Water Supply Well: I7sCREEN
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft, fL ,in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft, in. •
❑Industrial/Commercial ❑ esidential Water Supply_ (shared)
>18:GROUT'°-.:�...:::.• - - -
❑Irrigation DWells>100,000 GPD FR TO MATERIAL EMPLACEMENT METH &AMOUT
Non-Water Supply Well: J ft. D� ft. ( b_; ?
❑Monitoring ❑Recovery ft. ft 'v
Injection Well:
ft, ft.
DAquifer Recharge ❑Groundwater Remediation
1%SAND/GRAVEL-PACK(if '-:.:- -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING-LOG:(attach addititinal sheets if necessary)Y.,.-
FROM TO DESCRIPTI N(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O .. 020 rt.
4.Date Well(s)Completed,)4��� Well17)# Oft. (i ft. f �a�
5 .Well Location: ::‘ Liu". Cpc f'3b0,3- , hGU ( .
C11 'Pe an Q1 c.r (o3 ft t0 ft 61 a vevi.i-t-
Facil�Owner Name Facility ID#(if applicable) Q ft. l) ft. V1 _ K J q I� f
T
16 f CI(o ir�1,.4 I _c . v ft ft 111���(((���--�aa r t �-
Ph Address City,and ip ((���� ��AA ft ft. 1`^• ^'"'y• ;• �, T 'i
j nr c-r I � 66 73 IL7 21:RE1VIARKs t'"'74 r, x .e�.
A '
County Parcel Identification No.(PIN) ,y P p� ? h 7074
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: k r°J y _;f,,_,;�ti��.._ D
(if well field,one lat/long is sufficient) (�( (' Q 22.Certif ation: ..
35 55le 0 N 70 6 O 'T 1 0 N W GedOt`
3 ap act
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signatu of Ce ified Well Contractor Dace
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 AINo 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out A7101471 well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 remarla 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
`
9.Total well depth below land surface: ` 50 (It) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2©100)
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
1 10.St water!eve!is above casing,use'+'• (f t) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If 11.Borehole diameter �, (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
' y� 9 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well c 1.1 , ction method: �'\C� vs 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auge rotary,. ble,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) (�V Method of testacy Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: l•'{'I Amount:

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: re (•i )"
.1-f re "Tcce'er lackki I 6. lc.SLY") "'14:'WATER ZONES.. . ". '. . .. : . - _ -.
Well Contractor Name - FROM TO DESCRIPTION
ft. ft
q40 D a-.. • . : 1$® ft,' ft.
NC Well Contractor Certification Number -
15,OUTER-CASING`(fonmulti-cased wells)`OR LINER(if ap licable)'
22 L L.
�1n LcI I J el / 22r 1 a;
n J,C FROM TO DIAMETER THICKNESS MATERIAL
om / / / A ,` / ft Li LI ft //g in. •/pZS I /- uC.
Company Name V
-" 'ZC' `16:INNER"CASING:OR G TUBIN (geotber'inal dosed4abp)r' :
2.Well Construction:Permit#: a.SW? 2 --1�O Y'71 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
., 3.Well Use(check well use): ft. ft in,
i Water Supply Well:
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public.,� ft. ft in.
❑Geothermal(Heating/Cooling Supply) l�rlcesidential Water Supply(single) g, i. in, -
❑Industrial/Commercial ❑Residential Water Supply(shared) ..18:GROUT °.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (? it. p2 Q ft. arcfrn„:„*., PDure. /
DMonitoring ❑Recovery ft. ft [1
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-19,SAND/GRAVEL PACK(if applicable)::.`.' .. -
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) (]Tracer '=20:DRILLING-LOG(attach additional'sheets.if necessary), ": . ..=>.
FROM TO DESCRIPTION(color.hardness,solWrock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. rt. �� ` �
7
4.Date Well(s)Completed:2 10 j Z34 Well ID# i 0 ft 2.5 ft. \D•c.t�,‘ 4.i co../
5a.Well Location: ::y� . ,Zc- ft. "A66 ft b Li Cic-C;r.14.e •
`
(6pvGr T11. ev—S . ft. ft.
it r
Facility/Owner Name i ,_ Facility IDD#(if applicable) (� ft. ft
'24S Pfi\ � f4-, f\�"�e vVi tiID_ ft ft.
fihysical Address,City,and Zip i ft. ft, ; -t ,,.'L.i V f,'...,*"
,a .1.)
re `‘ 46.3G -1 Li- 1(2 2l.REMARKS: ..:: : _-::.. APR 2 6 L t 2
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ij.,y U,.'5`)U
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): Qmanent or ❑Temporary i deettl Well Contractor Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance wish
7.Is this a repair to an existing well: ❑Yes or CYfvo ISA NCAC 02C.0100 or ISA NCIIC 02C.0200 Well Construction Standards and that a copy
!fads is a repair,Jill out bvrown well construction information-and explain the nature of the of this record has been provided to the well owner.
' repair under#2l 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: / f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '� 0 -- (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: t (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use C�J//"+"
11.Borehole diameter: 7R (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: We 7f' t/ t,/ 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
QQ ^ •
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) V Method of test: t /^
13b.Disinfection type: 14 T t Amount: 3-y0 i nfs