GW1--04323_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
I.well CoDtnctor lnfortnatioD:
n � R! , _�/ , 14.WATER ZONES
Well ConlractorNarne 7 FROM TO DESCREMON
r D 'L .2A n /D $fA,
.36 �1 R.
NC Well Contractor Certification Number l' /^ I&OUTER CASING for multi cased wells OR LINER if licable)
.chs>lea s t 4// Dot(I/K 11 C• FROM TO D6 EfER THICKNESS MATERIAL
C4mpany Nam
/t-ft G L R t ,P-14 o 1tGUc-
// 16.INNER CASING OR TUBING t eothermal dosed-loop)
2.Well Construction Permit#: ��(r?8�9 FROM 'to DM►METER 711:100"Ess atwTERw
List all applicable it-ell construction permits ti.e.UIC.Courml.State.Variance,etc.) R (r rn.
3.Well Use(check well use): R. It.Water Supply Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTS12Z TIIICICQm MATERIAL.
❑Agricultural ❑MunicipaVPublic R. ft.
❑Geothermal(Heating/Cooling Supply) )kesidential Water Supply(single)
R. ft.
❑lndustriaVCommercial ❑Residential Water Supply(shared) I&GROUT
❑Ini ation ❑Wells>100,000 GPD FWM. To MATERIAL EMPL.ACEMLW METHOD&AMOUNT
Non-Water Supply Well:
e
LJMonitoting ❑Recovery b�xflnt
Injection Well: r
R. R.
❑Aquifer Recharge ❑Groundwater RemediatioD
19.SAND/GRAVEL PACK if a IicaMe
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMM ACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage R. R.
❑Experimental Technology ❑Subsidence Control R R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑ n2 FROM TO DESCRtMON(color•hardness,soillrock h sim etc.)
(HeatingJCooli Return) ❑Other(explain under#21 Remarks) n R s
4.Date Well(s)Completed.�� weil lm C R Q ft• B
Sa.Well Location: a '� 6 R °11
f�
JJ
� •Sl In er✓e_t- � 5 � �2 lam r V.-A i.kc /v
Facility/Owner Name Facility ID#(ifapplicable) ft. It
✓� I R4 5,,At1IJk+V-' Rf-.1�2A #44442 r50M AC LIS-3-7 ,-
Physical Address,City,and Zip IL rL
/
�
Vgf1Cr_ 21.REMARKS
Canty Parcel Identification No.(PIN) J U L 2 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.C cation: DIA': S��43 `
3 N 7S' �1 ���- W
6.Is(:tre)the well(s): ) ermanent or ❑Temporary gtraturc ofC Pied V c) ntractor Dat
IN signing this form.I he{ebv certi/.i,that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or '*Vo 15A NCdC 02C.0100 or 15A NCAC 02C.0200 Well Convtruction Standards and that a copt•
//'thin is a repair,fill out known well construction information and erplain the nature of the oj'this record has been provided to the well owner.
repair under#21 remarlq 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: 1 24.SUBMIWAL INSTRUCTIONS
9.Total well depth below land surface: .7&S- (ft.)
For multiple wells list all depths ifdifferent(erample-3(ir).700'and 2(f,/00') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above eating.use 10.Static water level below top of casing: a O (R•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
"//+"
11.Borehole diameter: b (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /41 IL Gz�fi 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) corm environmental health dep
artment partment of the county where installed'
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells producing over 1LM 000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1
13m.Yield(gpm) Method of test: /< 611
/f% C
13b.Disinfection type: Amount: g0
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018