GW1--04247_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
/ 1
_je_ C rev zeClfY/',1 &,-/n jla.c/S on 14.WATERZONES
Well Contractor N me FROM TO DESCRIPTION
ft. S�� S
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased asetl wells OR LINER if a livable
C FROM To DLq�IETER ""CKVESS 5ATERIAL
/ ft. Ll S ft. / 1"
Company Name ` `� VILA
!� 16.INNER CASING OR TURING(aeothermal closed-loon)
2.Well ConSITUChOn Permit#' r FROM TO D45D1ETER THICKNESS MATERIAL
List all applicable well construction pernits(i.e.UiC,County,State, Variance,etc.)
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriculturdl ❑Municipal/Public ft. ft. m.
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
rri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o
❑Monitoring ❑Recovery
Injection Well: —
ft. ft.
❑Aquifer Recharge ❑Groundwater Retnediation —
19.SAND/GRAVEL PACK it applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. rt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness,s Illructe type,tz aln size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. 10 /
4.Date Well(s)Completed: 'SZ Well ID#
�r J/
Sa r--.WWell Location: tt S�(/t 4 L[
Facility/Owner Namee r1n Facility ID#(if applicable) ft. ft.
/
Pltysical Address,City,and Zip ft. ft.
nq ,:3 - h /-�- 21.REMARKS
County Parcel Identification No.(PIN) ^`� -'eke
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35. o o(, oS , go. S '7 3 � 7 W
6.Blare)the well(s): HPermanent or ❑Temporary StgfiatOACeffiffied Well Contractor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 316o I5A NCAC 02C.0100 or 15d NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.Jill out known well construction it formation and e-rplain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fornn.
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 G -1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '550 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 1@100�
(fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: ✓ Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1 6 1 7
If water level is above casing.use"-
11.Borehole diameter: �8' (in.) 24b. For Injection Wells: Copy to DWR, Underground injection Control (IUC)
Q Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /� 0 f a t/ 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
r 13a.Yield(gpm) � Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: t) 7 Amount: ;n