GW1--03379_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor InforInformation:v e ceeci ec/Get vc., 3 f.Sc� OI? 14.WATER ZONES
Well Contractor AMCsoFROM TO DESCRIPTION W
1-i Co 0 o2. ft. rt. t S 5t36,5
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
P. t, /�ci��/�S GJel! 17r;Clin n/C• FROM TO DIAMETER THICKNESS MATERIAL
Company Name / n / rL en
// in. a 05 Pi/16.INNER CASING OR TUBING(gveothermal closed-loop)
2.Well Construction Permit#: t±�S 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
Y 3.Well Use(check well use): It. rt. in.
Witter Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipavPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) ;idential Water Supply(single) ft ft. 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, n. OM
v a 4 �e� Ps Li_re
❑Monitoring 0 Recovery ft. ft. -
Injection Well:
uifer RechargeR. ft.
❑A
q ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK(inapplicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control ft. It.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type gram size etc.)
L O ft. a O ft. ied C(c�y
4.Date Well(s)Completed:S-i2'7-021/Well ID# 0 rt. 5 o it. ,.5«.1 .574c-:..a._
5 aell Location:___. ,;- S 0 n• (l--/ft. Va.e _=Z1� •
m sh ill h' cr l�h/" 4/aa c4.� G.Q.K. o
Facility/Owner Name Facility ID#(if applicable) ft. R. ��r- r'
1
151 m ,f-m Fa rn1.5 Rd. rt ! v�, %.�.
*slog'Address,City,and e1lip �66ci; C ��I1 21.REMARKS
JU�
County Parcel Identification No.(PIN) n�FR.art' 1 tAiiiiieng
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 . 435411e N 80 i84l.23 w � _ 5-ay -ay
6.Is(are)the well(s): Yeanent or ❑Temporary S [ of tfied Well Contractor Date
18rm
_� 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 QNo 15A NCAC 02C.0100 or 1 SA 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.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '] CO ft
For multiple wells list all depths ifdij,rerent(example-3(a)200'and 2@100� ( ) Submit this G W-1 within 30 days of well completion per the following:
i 3 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R•) Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,use"+"
11.Borehole diameter: 6, �$ (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
pf� Program, 1636 MSC,Raleigh,NC 27699-1636
/L
12.Well construction method: t9 71-a sr,y 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 CW�ELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) a1 c,� Method of test: /�i/� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 4 'Tit Amount:3,'!t-1-.S