GW1--03453_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: /
_Te r e Y ../[�dL z//17 Ni CeC/f ge,n 14.WATER ZONES
Well Contractor N e FROM TO DESCRIPTION
1-1 iL IL
7O / /s, i �S
&O_2. ft. ft.
NC Well Contractor Certification Number
//lam/
15.OUTER CASING(for multi-cased wells)OR LINER(if ap[►4cable)
P . (»k ,'S WeI/ 29rI14tjZ �/7/c FROM TO DIAMETER THICKNESS I MATERIAL
Company Name fi I ft. y l0 It. & /4 in. • a S I f v c
k 7 16.INNER CASING OR TUBING(geothermal closed-loop)
7r
2.Well Construction Permit#: ! 0 a,L I 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): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipavPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1 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: 0 ft, aD ft. GY?C'„I _n,1C pD�/�C/
❑Monitoring ❑Recovery rt. tL f� tom `
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery OSalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,so OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
size etc.)
1, D ft. a a ft. ed 'C L
4.Date Well(s)Completed: -S-a 9.0 4'We»ID# h� d rt. 3 O ft. P,I:L 6..-1,w.tAp-C /
Well Location: •
3 D I�. W to ft. P. t�/ta.Haf / .e 6,-", _,
W"-A" C-Z-eS.'
W& rL a oo' .2?1 t° G A-.
acility/Owner Name Facility ID#(if applicable) ft. ft.
-3c o Camp Me[Q� Rd. ft. ft.
Ph 'cal Address,CCity.and Zip rJ [� ft It, 1.•L /
U T'lY1 �� n / i I 21.REMARKS I i 1:,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i) ,
(if well field,one lat/long is sufficient) 22.Certification:
,' S. Sal11o '7 N t1, B00S0 W � _
6.is(are)the well(s): 1131termanent or ❑Temporary SlgftatdfryR(�ied 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 io iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If ibis 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: n 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: o Submit this GW-1 within 30 days of well completionper the following:
ft.
For multiple wells list all depths ifdii different(example-3®100'and 2@100') ) Y P
1 L d 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft") Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-I617
if water level is above casing,use/+_"
11.Borehole diameter: tr7 � (in.) 24b.For Infection Wells: Copy to DWR, Underground Injection Control (IUC)
n fa Program, 1636 MSC,Raleigh,NC 27699-1636
1�
12.Well construction method: e r t/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) l county environmental health department of the county where installed
FOR WATER SUPPLY WELLSnn ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) / V Method of test: A i/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: / 7/ I Amount: _3 P; LS