GW1--03161_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
. , i&le-40 F Cam« ,
�Y� � ��-�-- 14.wA7ERzor>Bs
Weil Contractor Name FROM TO DB8[stlr,ol.
372-14- 3�8'-c Z�� lob st ,Ai/5 0
26.1 $- l 2 7 it- tj 9
NC Weft Cootractor carist>rioaxastiber 15.OUTER CASING(Sir was)Oft LINER(if )
�.�
/�i.1./L .W�"�- S /4-6 6,./5 FROM ft. _ - b� 1»[7 MATERIAL
Cry Name !
16.INNER CASING OR TUBING(gedYeead dssaLMp)
2.Well Construction Permit#:�'1), 6 .9 b�/- Z. FROM TO MA/TRIAL
List all applicable welt construnttan pensits(Le.f1TC Canty.State.Variance.etc) 141 Q- f 7i 2- n 4 r in. S e.4 ) Ve -
3.Well Use(cheek well use): /z.7 IL .l 2-9 ft Yj' i` Z. Y.i P i4C
Water Supply Welk 17.SCREEN
FROM TO nlAMEfl SLnrrS/2E IHICIOUISS MATERIAL
Agricultural 0Memicipal/Public / 7 z11- /a-' tt- 4 m. Zd 36 V SS
[Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) t. ' rt. to <
DIndustrial/Commercial DResidential Water Supply(shared) 1R GROUT .
❑Irrigation [Wells>100,000 GPD FROM TO MATERIAL IMPIACEZIErr METHOD&AMOUNT_
Non-Water Supply Welk- j) °' Z J n' //4j`10/Ill /7 LI 41.1.. - i
wing ❑Recovery n. ft.
Injection Well:
tz ft.
t7Aqurifea Recharge [Groundwater Remcdiation 19.SAPID/GRAVEL PACK(E-T )
°Aquifer Storage and Recovery [amity Barrier FROM TO MAMMAL. EQIACStMrrMETHOD
DAquifer Test OStonowater Drainage Z,/ n- /Z f I- �'•S-�.024 ,d[t/L
[Experimental Technology ❑Subsidence Control it. ft.
°Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(nand adds tied sheets dams-y)
❑Geothermal Coolm tlt gReturn) °Other(explain under FBo TO i tr earn ,.. :,pe.aat.+t.�..oet
a t G e ,z
4.Date Wen(s)Completed: /b-Z4I Well ID# (pd IL eel IL -sae- 610/4
G
5a.Well Location: Get R' /27 ft" d/Yt<sdiorie.pi•'e.SAva
�ere/z 6-6-10-60,1tA-- - . /3? tt' 10a IL ni1404.-i- S44_, in ix
FsedityiOwmc NIIIIIC Facility IDS(if applicable) it. #-
ID
37 r ..k.s CA 4 &l. 2a A-n if oM.1er tV - ft. It.
Physical Address,cry,and rip .215' ". IL , °- i L,. L U
qi ell nt foie/ /Lk IZd0 3.s i/12/ 2L REMARKS
Comity Parcel 1ae lion No_(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,me latnong is sufficient) 22.
tion:a 3 72 i? 3 3 7V-
o 3 . x 79° 37 ice ya1 J so� �c/J. r,:J ' -
6.Is(are)tt a wef(s):J3fermanent or {7Teauporary Signatory of Certified Well Contractor Date
By signing this form.I hereby cerS fythat the well(s)was(were)constructed in accordance with
7.Is this a repair r to an existing well: [Yes or jsJNo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Coaslnction Standards and that a copy
(finis is a repair,fill out known well corisirudion information and explain the nature of the been prnvidad to well owner
repair under 121 smarts station or an the bock of this form
23.Site diagram or additionall well details:
$.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide a additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( Over'in Remarks Box).You may also attach additional pages if necessary.
drilled 24.SUBMITTAL INSTRUCTIONS
9-Total well depth blow land surfice: /0.4 Op Submit this GW-1 within 30 daysof welt completionthe following:
For multiple wells list all depths ifdifferent(t'mm�ple-3@200'and 24100') P per
10.Static water level below top of casing: ,. 24a. For All W� Original form to Division of Water Resources (DWR),(
Ifwater level is above easing,use~+- Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
u_Borehole diameter /'I On,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12-Well constrnetion method: L71 u4. 21 ! 24c.For Water Supply and C►Erm-Loop Geothermal Return Wells:Copy to the
a(` eager rainy,cable,
direct push.�`_) / county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1004100 GPI):Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) f3 Method of test: pi r79
13b.Disinfection type:f4c4/ ,rit*1'<,_ Amount /26
Form GW-1 North Carolina Depalua t of Environmental Quality-Dhision of Water Resources Revised 6-6-2018