GW1--02604_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
Ke.,/tol v. 4d , / 14,0., gier:.6 -14.iWATER ZONES -- -
WellContractor Name ,>• FROM TO DESCRIPTION
Q� ft. ft
ZD • �t.' ft.
NC Well Contractor Certification Number • 15..OUTER CASING(for multi-cased.wells)OR LINER(nip licable)-5•:_.• -'
/J�/ i]� A
l FROM TO DIAMETER THICKNESS MATERIAL
Company G me Allis.
/S ��P/[ I l" /17Lft. (/'7 ft. 6%k in- , Z O AiV
P Y 7 J
/)�1 16:INNER:CASING:ORTUBING:(geothermalclosed.loop)C=... '•
2.Well Construction 7 Permit#:' Cfff -lab-2OZ3 OU0/Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(cheek well use): • ft. ft. in.
Water Supply Well: I7:SCREEN -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in. '
❑Geothermal(Heating/Cooling Supply) h.Residential Water Supply(single) ft ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000GPD . FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft" lid ft 4.f+�4®�t46 Aa/
❑Monitoring ❑Recovery ft. ft �
Injection Well: ft. ft.
❑Aquifer Recharge, ❑Groundwater Remediation
"19.SAND/GRAVEL PACK-(ifapplicable);: <.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft. ,
❑Experimental Technology ❑Subsidence Control 1 ft. ft.
❑Geothermal(Closed Loop) ❑Tracer - •-20.DRILLINGLOG(attach additional sheet ifnecessary) -- :;r. . . •._.
FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. . ft. c. l
01.
4.Date Well(s)Completed:7 D Gi YWell ID# 5' it -z4-, ft- 6 ' 5-4de„
Sa.Well Location: �:- ,;- ,� YZP ft. g� ft 4C..., Sict.IL-e_.
le 1J<L-.5eS`l'It'." 40e,
Facility/Owner Name` L ) Facility ID#(if applicable) "y• ft ft.
3 40 i/6,j MI Sco TT Z.Q ft. ft. I.::: :;....: F, ' - tfr I,..L.•)
Physical Address,City,and Zip ft ft p r) q r r' /,
-fJCa.✓l�kS • 21..REMARICS:. ,• ::.• .'.+ Hi•ll\_.'--'L... . .. ._ . . - -
County Parcel Identification No.(PIN) o'r•. Ms: q t +
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D's�
(if well field,one lat/long is sufficient) 22.Certification: •
3S 3 7c3ikg N gO %/0L6 6 w 2`��� y-g�2
6.Is(are)the well(s): IDPermanent or ❑Temporary ignature of Certified Well Contractor Date\
By signing thisJorm,I hereby certify that the well(s)was(were)constructed in accordance.wlth
7.Is this a repair to an existing well: ❑Yes or0 ISA 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 explain the nature of the of this record has been provided to the well owner.
t repair under#21 remark 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: �J 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /�� (f) Submit this GW-1 within 30 per days of well completionthe following:
For multiple wells list all depths ifdierent(example-3@200'200'and 2 a@100) y p g'
i 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 35 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: fo
/%/e (in.) 24b.For Injection Wells:Copy'to DWR,Underground Injection Control(IUC)
���� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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) zi 1 Method of test: ,4/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: # 7, Amount: _5�/yrl S