GW1--04239_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name % ft. fL
-Z,0319 i ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER t a ►icable
nz S // nl f� FRO31 it TO ft 0"METER in THICtNESS MATERIAL
Company Name j U,'J �L ' 6 O G
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: e/� /0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Valiance,etc.) ft. R• m
3.Well Use(check well use): ft. R In.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOTStZE 7'HICtCNPSS I MArelilwL
❑Agricultural ❑Municipal(Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) llf6sidential Water Supply(single) g, tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation C]Wells>100 000 GPD FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: Q tt. .L� R t�
❑Monitoring ❑Recovery i4 R
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)._
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLA I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage n' R
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION calar,bardnew,roll/rock qpp,graln size,eta
n. " fr.
4.Date Well(s)Completed:j '�6'�� Well ID# ft ft. G
5a.Well Location: rt. tt.
,� I C G
-t- se_ Ic1�c L ` _ 6 S IL 9/ uG a-f'
Facility/Owner Name Facility ID#(if applicable) 71 - 6 5,51 R.
ft_ It. ..
59Z� Pie-- ✓. �Iat.l mac/
Physical Address,City,and Zip a n ft• t
�4 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one latllong is sufficient) 22.Certification:
3y.gL�'z� N �C7. � �gs� W '
6.Is(are)the well(s): [aWrmanent or ❑Temporary Signature of Certified Well nttactor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or S14o 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and(hat a copy
If this is a repair,fill out known well construction information and esplain 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: /rr 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16 JO (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 1®1001
/, 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7 (ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ljtwater level is above casing.use"+"
24b.For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter: 6 LQ // (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: z T_✓a-.. 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
Permit Program,1611 MSC,Raleigh,NC 27699-161
Method of test- 1
13a.Yield(gpm)^�,_ /✓ L
13b.Disinfection type: HT/// - Amount: �Tl