GW1--04293_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:! /
J e FF, y 7;GC/L er--/�avt el Je _disc I 14.WATER ZONES
Well Contractor Nafne FROM TO DESCRIPTION
�' ft. ft. g5l 9oJ iel51 /` 0
ft. ft
NC Well Contractor Certification Number
VG� q� 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
C. MGGII/s (.v l �/I�IlI/n4•-�/1/C MATERIAL
1 ft. (,1/3 ft /_/$, in. . s THICKNESSmost TO 4 DIAMETER /-!/c
Company Name / t� l�J
a oa y �0 Q is 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ^ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) n. ft, in
k 3.Well Use(check well use): ft. rt. In.
' Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. n, In.
OGeothermal(Heating/Cooling Supply) ifftesidential Water Supply(single) n• n, in
❑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. e2 O n
❑Monitoring ❑Recove ry ft. fL �d 4 tee C1
Injection Well:
ft. it
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test• ❑Stonmwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. it.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
D n. a 0 It. 54 eilf7Con e
4.Date Well(s)Completed: 'mac 7-oZ iNell ID# 2 0 it. H3 It. e23 Li fl.
5a.We ocation: Z. in It. a Qa n. G)<j/ & .
c i/l�u �1- ft. rt.
�fJ c Gc e (, T
Facility/Owner Name Facility ID#(if applicable) ft. ft. _ .. , R -
It-
n- ft.
/06o/ rr1 -SD55 0,r eLn Rd.
Physical Address,City,and Zip ft. ft. j I /.11 J4
I,r L t 5 21.REMARKS T„
County Parcel Identification No.(PIN) fpt.":1".y
5b.Latitude and longitude hi degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36. a.'7086 N 8Ofsia3 .0 w -1 _ (0- ci7-ai,
6.Is(are)the well(s): Imanent or ❑Temporary fi ertified We 1 Contractor Date
SPer
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or If1 15A 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 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�]is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: U 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A D Q (ft)
For multiple wells list all depths ifdi different(example-3®200'and 2®100� Submit this GW-1 within 30 days of well completion per the following:
' a S 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Itit9--fret./^y 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
13a.Yield(gpm) / 0 0 Method of test: i j y- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /4 7-hi Amount: . 3 farm 71
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