GW1--03409_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: ter- - //
0-eFfce "re-c.c./1. r /Gad-in V etCJ `D 14.WATER ZONES
Well Contractor MiniFROM TO DESCRIPTION
� o�. f. ft. SS1 7S2 10, a 8S
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ►icable)
l• L r f1{/(i/ S well „Qy)c L is YL Z/1JC FROM TO DIAMETER THICKNESS MATERIAL�p
1. / ft. ti 3 fL /iv, in. ► a 5 1 e C
Company Name /
16.INNER CASING OR TUBING(geothermal c1osed400p)
2.Well Construction Permit#: a'/O 3 ( ' - O / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consttitction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public It. ft. in.
OGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) R, n, in.
❑lndustrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Welts>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. el O ft. Of9 A___ „ _
❑Monitoring ❑Recovery fL ft v ���'�`
injection Well:
ft. R.
0 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.
OExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO I DESC ON(color,hardness,soWrock type,grain size.etc.)
b ft. oZ D `L e d e 6a..y
4.Date Well(s)Completed: .S-9- Ail Well ID# nl 0 ft. yJ ft. .8 L .e. t;
•
5 ell Location: (t ; y 3 f' 3 O ei R' 27�t e G.t.e...;ze.
` jer-ri'� `Ili(\ ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL R.
747 al Sky ta'n,.. 'if?. ft. ft.
f
'Physical Address.City,an Zipft. It. ("t
- ,U LA 0(00(-I(��3 97 . �.`+ v �Lr
2l.REMARKS AA
County Parcel Identification No.(PIN) (� ���
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: irrtcrtx Wit'n f►ccesapir1 I Bait
(if well field,one las/long is sufficient) 22.Certification: DV,'Qi150479
35. S6075 N So . 99 t3 W .� A.-T 5-7- aii
6.is(are)the well(s): ermanent or OTemporary �atu oed Well Contractor Date
_ 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: DYes or aivo 15A 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.
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: 0 (/'l 24.SUBMITTAL INSTRUCTIONS
t�
9.Total well depth below land surface: .3 (R) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 r@200'and 2©100')
10.Static water level below top of casing: cQ.S 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
11.Borehole diameter: //
l� /i? (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
D Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: _ RD 7 t fit,/ 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I C) 0 Method of test: 61 r
13b.Disinfection type: FJ T f? Amount: 3 /0,-4+S