GW1--04189_Well Construction - GW1_20240717

ASTRUCTION RECORD(GW-1) For Internal Use Only:
/ ..oniractor Information: �j
1`„t�/�[P-f 7v'`v/)�ijL a/Y 1.9 /d.i4..,a rim_ 14.WATER ZONES
Well Contractor Name Fly TODESCRIPTION
ka a- /6 81 n- t. )rn le „t,
NC Well Contractor Certification Number 15..OUTER CASDIG Oar dH-®ed wens)OR LINER(i
et{.!, �e L4abdi/i14 X1 FROM TO tMUCHNESS o-
Company VIAL
Name
16.INNER CASING OR TIMING(geothermal
2.Well Construction Permit#: 5-6/3� FROM TO DIAMETER THIN) _MATERIAL
List all applicable well construction penni s(La.U!G County.State.Variance.etc) "141 n- /Q 3 1t- y/ii bl- ...16 4f V p►/('
3.Well Use(check well use): /oYn //O IL lie S[,-if() i9 1"?
Water Supply Well: 17_SCREEN 7
FROM TO DIAMEIIR SLOTS THICKNESS MATERIAL
['Agricultural OMtmicipaUPublic /4)3 ft- /43{i R. z/t nu. .06
3d C{ s 5
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. Q $ in.
❑IndustriallCommercial Miesidential Water Supply(shared) Ia.moil,. .
❑irrigation Dwells>100,000 GPD FROM TO it. EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: eJ -it. . / ILTIR
/:1 g4} f 6CYL
['Monitoring ['Recovery IL [t J
Injection Well: • -- —
tt ft. k
UAquifer Recharge DOroundwater Remediation
19 SAND/GRAVEL PACK(/f appll able)
['Aquifer Storage and Recovery . OSalinity Bather FROM To MATERIAL EMIt AC>snarrMETHOD
['Aquifer Test ❑Stormwater Drainage i2Q ff
❑Experimental Technology ['Subsidence Control ft. tL
DGeothetmal(Closed Loop) ['Tracer 20.DRILLING LOG(alaeh additional sheets if aeetsary)
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardens soahodct7pe grain )
v IL 24-'- I- ,z%os....`e_ y _ y
4.Date Well(s)Completed: 6`i?1.-LtWeli DO 4 <B- /15' ' ',e1Hj e_ -
Sa.Well Location: / !OS n' �c u it' 6:140iZe- /171/.0
Facility/OwnerName Facility 11)6(if appiicable) -/O1 R' lZ5.' R' /'A.wjL itAj ci-•''..(��J
3 ci•yL /J Zw' I ix1R t ,t1, L--0)`e, N`— a ft. J
Physical Address,City,and Zip .9:1317 ft ft.
(7't 0,to �r7.tle))°77 z- 2L REMARKS
County Patel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one tat/long is sufficient) 22.�tion:
3s° ci t a t/ N 79
9 7 i, [ :51
1
W
1641e, /?ruij/1
6.Is(are)the weU(s):)Vermanent or ['Temporary sigma=of Certified Well Contractor ['arc
By signing thalami.I hereby aatifylhm'the well(s)was(were)constructed in accordance with
7.Is this a repair to an misting well: DYes or ANS iSA NCAC 02C_0100 or I SA NCAC 0iC.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 621 rernanis section ar 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 dicate TOTAL NUMBER of wells (add Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surfer= //C (ft-) Submit this GW-1 within 30 days of well con letion r the followi For multiple wells list all depths//different(ermnple-3®200'and 2®100') y' P Pe nS=
10.Static water level below top of casing: 4'r (.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing.use"4'' Information Processing 1Jnit,1617 MSC,Raleigh NC 27699-16)7
b_For Injection Wells:
11_Borehole diameter: (in.) 24 � Copy to ODWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I/1 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(_e_anger,rotary,cable,direct push.etc)
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produant.over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /5-7 /'1 S Method of test_ p Li'1 putt Prograro,1611 MSC,Rale�gTi,NC 27b99-1611
13b.Disinfection type: kJ, .-4 Amount:___ Z/10
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resowon Revised 6-6-2018