GW1--03926_Well Construction - GW1_20240705

WELL CONSTRUCTION RECO (GW-1) For Internal Use Only:
1.Well C or.Information:
'14.WATER ZONES
Well Nsij FROM TO DESCRIPTION
/0 p f t. 02X�)ft
S9 7 4 ft _ft
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap ticable)
t 3r0 m -_.v$ FROM TO DIAMETER THICKNESS MATERIAL
(i4it/ (t ft In.
Company Name
D / 16.
FRDIAMETERiMYER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: }- fI FROM TO THICKNESS MATERIAL
List all applicable well construction permits e.UIC,Corm0',State,Variance,etc.) .•1- I ft* -77 ft `5lie hi /7T t_,.r it_ ?YL�
3.Well Use(check well use): ` R• ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
❑Agricultural DMunicipnl/Public ft it. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. f_ In.
❑IndustriaUCommercial esidential Water Supply(shared) lg.GROUT
❑Irrigation _ ❑Wells>100,000GPD FROM TO MAC • EMPLACEMENT METHOD&AMOU
Non-Water Supply re* ;` , -t i> ft. �iL ft. 1/ec -
❑Monitoring ORecovery ft ft
Injection Well: I I �. 202 Pn( ` -+
? C -,rt-.•f
' ❑Aquifer Recharge t r Groundwater Remediation ft ft t
❑Aquifer Storage and Recovery ' []Selini Barrier 19.SANDJGRAVLL PACK(if applicable)
ty FROM TO MATERIAL EM� ENT METHOD
❑Aquifer Test t ❑Stonnwater Drainage ft. ft \�
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG ttach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,bardnen seiVretk type,knm sir.,e t)
// R. ft.
1
4.Date Well(s)Completed: 9 -ZVWell DM ft(p ft. (`(al 1 Y rl t V t.•-• __��
5a.Well Location: it J Y'hn eD rjb ) ft. 2 2 ,f u3 ,�
• Facility/Owner Name Facility 1D6(if applicable) ft. ft
I BD a hi-) BrAce-Y Rd ( Cr(_t h•-vDit/1,/� ft. tc U.),
Physical ddreas,City,and Zip
"3 21.REMARKS,) `o,
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.CCrti "on:
36' ' "13N �/ / 21 ' t5/ ' w . .4 ,
(, - Z. , 2
6.Is(are)the well(s): Permanent or ❑Temporary `) )( ) I Signs of s ." - ell Contractor Date
�1 `L esr- O vv By signing th form,l hereby certjy that the well(s)was(were)constructed in accordance w
7.Is this a repair to an existing well: ❑Yes or 1No 15A NCAC 02C:0100 er'15A NCAC 02C.0200 Well Construction Standards and that a cc
If this is a repair,fill out known well construction Information explain the natal.,of the of tins record has been provided to the well owner.
repair under 021 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 some 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 necessai
drilled:
�� 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: (ft.)
For multiple wells list all depths If different(example-3 c©200'and 2©100') Submit this GW-1 within 30(lays of well completion per the following:
10.Static water level below top of casing: 66 , ) 24a. For All Wells: Original form to Division of Water Resources (DWP
If water level is above casing,Arse"-I-"/, r/V ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ` (in.) 24b.For Injection"Yells: Copy to DWR,Underground Injection Control(IU(
l Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: O t ai ri - 1 r _
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to th
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
13a.Yield(gpm) Method of test: A; r Permit Program,1611 MSC,Raleigh,NC 27699-1611
is
13b.Disinfection type: 0 ) I-I Amount: iri;