GW1--04472_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
'C)hAI\c \l-e1,S\e.y o'lt' 14.WATER ZONES
' )e-tt r 4 FROM TO DESCRIPTION
Well Contractor amc •4�i, '''�, 1Sas ft. I (_5- it. I C) G'9M
?c I P
NC Well Contractor Certification_^ Number1 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
I ey / 1�, ' l\ i) 11 Tee, FROM TO DI t METER THICKNESS MATERIAL
Y rS VI I 1 4-- ft- (Q7 rt_. 6 I Y in. o O2-1 PVC, +
Cgtnpany Name lb.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 03(QS-F-S FROM TO DIAMETER TIDCKNESS MATERIAL
List all applicable well construction permits lie.U/C.county.State.Ianance,etc.) $1 R. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN hf
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑MM/unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 9Residential Water Supply(single) R. ft. in-
❑lndustrial/Cornmercial [Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /) It. r)„,) ft. / r„n._y 9 11..1.•c).R.„
UMonitoringcton ❑Recovery 1) ft- r1-1J D. 1_-, a-.+6C-1. �t t,�(3
Injection Well: ` U. fL X 1 \l/ ��CJ ` `,v
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) A
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. It.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(I leating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sotUr ck type grain size.etc.)
O ft.
�acJ IL Sq- 1 ''-l-e}
4.Date Well(s)Completed: I7 1-IS a.Daf Well ID#Lf D. (CS-8 (OD n• 'JD it• C'/, _t`men -Qry
5a.^Well Location: �^ 0 ft' F`_5- n J��`Ca0. ("c rt
ECI C s-FDM �ecie_J fL 10 H.
Facility/Owner Name f Facility lD#(ifapplicabk) n H.
1 9 Poi-A(: c?iCe- D1r 1\fe Cr HorC� ft. rt. .5., " __,
Physical Address,s/City,and Zip }Q t �c�(� (� n ft. {� �y
Gcanv 1,\e, 1 CJ 1 4 o0 l.�j /( 19 21.REMARKS JUL 3 0 2024
County Parcel Identification No.(PIN)
A 1jp.x
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ()WC,:Rt'
(if well field,one lat/long is sufficient)
22.Ce.i � anon:
2b.0(W(4 0 N-l6eab-1 'I i W %'
07/7-3/..),o_2.1
6.is(are)the well(s): ermanent or ❑Temporary Si_ .curt of' nified 1 r Date
/3r'signing this form.I hereby certi/i•that the ere/1(s)was(were)constructed in accordance with
7.is this a repair to an existing well: [Wes or tio 15A NCAC 02C.0100 or ISA NCAC 02C_0200 Well Construction Standards and that a copy
if this is a repair,ill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark;section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I i W-I 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: t fps (it.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(0200•and 2(a1/00')
24a. For All Wells: Original fo 1617 MSC,Raleigh,form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) a Information ProcessingUnit, NC 27699-1617
If water level is above casing.use"+"
II.Borehole diameter: (C (in.) 24b.For injection Wells:Copy to DWR,Underground injection Control(iUC)
t/��/ L Program, 1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: Q..t 1 \ f J��Y 24c•For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable.direct push,etc.) f 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
�-I Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) ' Methodtn of test: t( ),
13b.Disinfection type:VI ypO�\r(•Ve Amount: 5v�-
n Fon(iN'-I I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018