GW1--03482_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: //
JeFFrey �ctc.Kec / (G.vIn cfcC/I'Ser) 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
• ft. It. (/bJ / HS /`3D
L/(oO a- ft. rt.
NC Well Contractor Certification Number L� 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Ilcable)
Rom, `-.. (Mew;//;s Well L/r;l l;A .�C• f/OM 1 TC a- to/DIAMETERO THICKNESS MATERIAL✓L.
ft. ft / q in. C /_
Company Name 4 � J
/� 17 16.INNER CASING OR TUBING(geothermal closed-loop)
/
2.Well Construction Permit#: /o 0 t LI-T ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,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 ❑MunicipalPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IIIRCidential Water Supply(single) R. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. a O ft. 15Q4 ytoh;if pO c../e.d
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIIPTION/(color.Hardness soil/rock type,grata she etc.)//�� it. .2 O fL /C w2 Cv c ecLy
4.Date Well(s)Completed:S . 1 -,)"/Well ID# , Oft. 86 ft. ,$Ae f ,.3-f '/y._
Sa.Well Location: O ft, 1 oz ft. Lu e S .=� Q U
s
,Thu 5-1'jh H GL3t'S
Facility/Owner Name Facility ID#(if applicable) ft ft.
93 )& �3 c3'e F -Rd ft. ft, � :1-'vc iL)
Physical Address,City,and Zip ft. ft. A
in ecHL tP-1� b k 21.REMARKS Jl)N 1 1 ZO24
County Parcel Identification No.(PIN) )rlb:n'tw»C t+ ?-!,..a...-,./tl*,i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' ' C"
(if well field,one Iat/long is sufficient) 22.Certification:
35. 183.20 N 8 0 . (00 7 l08 W %,,E--t- 5" - I -ea'1/
6.Is(are)the well(s): Efl manent or ❑Temporary gne of rtified 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#CINo I SA NCAC 02C.0100 or 15A 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 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: 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t@200'and 2®100')
' c 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �J (ff) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
11.Borehole diameter //8 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: R0'Lary 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
m Almit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) a ll Method of test: /7 t r
13b.Disinfection type: hi 7H Amount: 7 pt`l17 f