GW1--03436_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
TeFFr- /leCAer viii ��CIJSOYI 14.WATER ZONES
TO DESCRIPTION le
Well Contractor Na FROM
ft. ft. G o q0 /o S 1 gS
l./L6.oZ ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licabte)
FROV C-• /17c,//,_S l vel( 29E el,>„, 2-nic �t ft. TO DIAMETER
ft. D�j/�,in. THICKNESS MATERIAL
Company Name
tom/ 16.INNER CA ING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): It ft. in.
Y Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) leesidential Water Supply(single) g. g• in. '
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
0 Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. a C/f1 R- C,r/ z 4 Ofa/C�IrG/
❑Monitoring ❑Recovery ft. ft r
Injection Well: ft. ft.
DAquifer 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.
❑Experimental 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 TO DESCRIPTION(color,hardness soiurock type grain sire etc..)
p ft. a v ft- `e/ft i C !ot,4.Date Well(s)Completed: i/ -�3_a Nell 110 a o f. S S ft �h /t S ne /Q
e c.Sl�tt lQ.
5a.Well Location: 58 IL l Li oft- V ec,e .sue-_
f-ii Cy Cii-vierilikhkik9 1 II 0 it ev et '756.,,P
Facility/Owner Name Facility lD#(if applicable) rt. It % Iq L,. °\,F--I '
l..
/5/O 4u-/TP V R, ft. it.ft. ft ' '\; 1 ] )1:i 1
Physical Address,City,and Zip hh
LG�Iien l!9- del nn/)
- c(Al) 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3i i. g3753 N go , 5a'i.!38 W - _ si -.13 -a2/
6.Is(are)the well(s): irmanent or ❑Temporary Se f ed 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: ❑Yes or 121Pe 154 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:
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r 't (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2®100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 17 0 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" /
I1.Borehole diameter / (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
n Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /► o 1-arV 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
ec Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) r21. Method of test: A/ r
13b.Disinfection type:14 / /7 Amount:.,,3 10i n 4-S