GW1--02798_Well Construction - GW1_20240506

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor ormation:
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1a.WATERZONES ` i
Well Cdctor Name FROM TO DESCRIPTION
4 1P -A a'1V R aid • �!s 6 r�
NC ell ConuacmrCertification Number 15.OUTERCASING(forMuld-casl Wells)_ORLINER(ifatt1MATERML
lIeeble)
Zz a c FROM TO DIAMETENJ„
!�ft- (7 m THICKNESS
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Co ny Nameft. :
16.INNERCASING OltI'[18INGYk'�fIIeimat dosdlaoop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UI County.State Variance etc) it ft. 1 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QM ipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) Blesidential Water Supply(single) R ft. in.
Industrial/Commercial °Residential Water Supply(shared)
18.GROUT-
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft•
Monitoring QRecovery ft. ft.
Injection Well:
ft. it
Aquifer Recharge °Groundwater Remediation
=:199 SAND/GRAVEL PACK(if applicable)";'
Aquifer Storage and Recovery °Salinity Barrier FROM TO )MATERIAL EMPLACEMENT METHOD
Aquifer Test QStomiwater Drainage 0 ft' ra ft• i k.4.iL i. f/.ut" tAi
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20 DRILLING LOG'(attueh additional sheets if necessary)
DES 1
Geothermal(Heating/Cooling Return) inOther(explain under#21 Remarks) FROM
ft TOft. N(tutor hardness,sotNrock type,gram size,etc.)
z � / Well ID# / e-7 1r
( 'J 4.Date Well(s)Completed: )t/ 12(J ft- /y„3 ft. ( ."v+.-e1 -
5a.Well Location: / t/,3 IL d7,G o fL r ,'r a- ,0�r`-e
sf-t-Ae j�Gsc-, 1`10)o a a ft.
ft.
Facie /OwnerName Facility ID# ifapplicable) ft. ft. L. ,__. '{ V
`1 /C (/t-�/7sA7c,(7/14Ti/,/ei a9/‘ ft' ft. ,A
Physical Address,City,and Zip ft. ft MAY 2074
G •, d/%7 6 S 6-$s�s02y/ 21.REMARKS 1f3. :. .. i rtisr%n:•.?lSie'
EYWOOOG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rX n
(if well field, latflong sufficient) O 22.Certification:p Vea n
c; , 7 G N !l d ‘5 w PA. �
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6.Is(are)the well(s) PPermanent or °Temporary Strata of Certified Well Contractor Date
By signing this form.I hereby certOr that the;well(s);was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a -.
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I remarh section or on the back of this form.
. 23.Site diagram or additional well details:
8.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: X v (f-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different(example-3Qa 200'and 2Q100 construction to the following:
10.Static water level below top of casing: Co' (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing. u""elj"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t-yll' (ID.) 24b.For Iniection Wells: In addition to sending the fonn to the address in 24a
P/ 727-p1/� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: t / "' construction to the following.
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield-(gpm) ( .J Method of test• ` --i ll 24c.For Water Supply&Iniection Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:ic "\ - Amount: 3.rp completion of well construction to the county health department of the county
where constructed.