GW1--02600_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
JIli/I I /r / So., lice. 14.'WATER ZONES- i
Well Contractor Name FROM TO DESCRIPTION
, /o 5-ft., 3Z0 ft.
Z03K it: ft. i
NC Well Contractor
�Certification Number A. ))] 15..OUTERCASING(for multi-eased•wells)OR LINER(if ap limbic) . ,
- '/�f//u//s , - )�// //rl/4n` FROM TO
' DLAMEETER THICKNESS MATE
Company Name ! I/t� / `{/ ` 74i ft
ye ft. 6 m• , z.7o VC
Q�J -16 INNER.CASING OR loop)? '
2.Well Construction Permit#: • .- /-- 7/50' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.NC,Counts State,Variance,etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water 5upply.WelL•
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft. in, •
❑Industrial/Commercial OResidential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft' 25' ft. b elr foy lie D 0`f red
❑Monitoring ❑Recovery ft. it.
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 Cl Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer -20:DRILLING-LOG'(atttich additional sheets if necessary) ..necessary),:' .-. :`::- -r-..= .
FROM TO DESCRIPTION(color,hardness,soil/rock ...
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
type grain size etc.)a ft. ,,. ft. re4 C(a y
4.Date Well(s)Completed: 3 " Z 1_Z °Well ID# )2 ft.
30 ft. ye/kw S./c-/-c'
5a.Well Location: ,/ :..`y, 3o fL 4'9' b Ate 5-62 e e_-
✓llba'gGu-� /fci l w ,i- q4 ft. 3 -Oft- // I/ _sour e I/ni es-fc7n r--
Faciillity//O�wtt�r Name ® Facility lD#(if applicable) ft. R. 1
//7 c,I /fir D ft ft. - `j"_,.;. .• 5 �� t_'J
Physical Address,City,and Zip it. ft.C_Xa �j
,�f a4/1.t j • 2LREMARIGS:--`=r:. :• . AF-R-2 u- 2624,
County Parcel Identification No.(PIN) . .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: .
3 , Z303o N iS®, S16 Z. 4 W ,e,‘/74,"1"//141/. 3-zi- z-Ll
6.Is(are)the well(s): rl'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certib,that the well(s)was(were)constructed in accordance.with
9.Is this a repair to an existing well: ❑Yes or .l 4o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair:Jill out known well construction information and explain the nature of the of this record has been provided to the welt owner.
, repair under#21 remark 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 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
/,2 9.Total well depth below land surface: 3 0 (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii different(example-3@200'and 2Q100')
10.Static level below of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static
tar level water above casing use top o 3 (ff) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If 11.Borehole diameter: 6 (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �b 7' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /0 ), Method of test: aY
13b.Disinfection type: ,1 �!'/ Amount: J,lar�� 1