GW1--04537_Well Construction - GW1_20240731

WELL LJorrJ IKUL R 1 1/Ii KIC,I,UKI) (lir W-1 I for Internal use Only:
1.Well Contractor Inforrmation:
71-a 9C h Poo 1"e- 14 vAtEtclo 3E a,5 .Y?M'ea A.: i.' .7�.•' .
(1 FROM TO DESCRIPTION
Well Contractor Name ..
�a1 qA ft ,
, 6 0 ft. io j eir
ft. f.
NC Well Contractor Certification Number -,.-44.p ,R-eASEc[(x(1'o aiulfi-based:Wel )D,A-'flPF1iH(If-'pCryli6abk):
Fa[1N 1 IT[1 I OiAMFTRR I THIr KgNFCC MATF.RI Al.
7 �f��` a r��� ���I PtA� �� d ft. I oG R. ( in. e / $ 4) V i h, FaL
Company Name e,(3 ;k
�j ;A6:INNER G.ASING!OR17'EFOING(geothermal ioaed4Oirny. ,.a ;
2.Well Construction Permit#: L 1 - ®bo Q g FROM TO '� DIAMETER _ THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Su ly Well: ':.I7,,SCREEN, , . .;riaalir r`':,rw:
pp FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural O cipal/Public ft. ft. in.
.-C;.y.. .r nr___.s_-,rn_.t:..,.cv.�t•h el-mti'.A 1V..w,..0......1..(.•:....t..\ _
... :::.:-:u.:..�.-__.::e.-`--'ro� rr ii _'---_--"_:^ _"-:= rr. .--o---� 41$.GR(Z'ff „^s 'S iP'.,
�industnallCornmercial ❑Residential Water Supply(shared) FROM TO r MATERL t".5 ,f EMPLACEMENT METHOD&AMOUNT:. ,..
❑Irrigation ❑Wells>100,000 GPD ti
Non-Water Supply Well: (p ft• ZQ tt• b�n"'�i1 rh., n�'o v(i
❑Monitoring ❑Recovery V ft. ft. J
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation -_
19.SAND/GRAVEL;PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM 1 TO MATERIAL EMPLACEMENT METHOD
D..y::.... ..,.,. _ ..:_._.�._. ft ft.
-
moo-
❑Experimental Technology ❑Subsidence Control ft. ft. .
❑Geothermal(Closed Loop) ❑Tracer ;s3ff. iRIt ,INGLOG(attachaddittonilsheetsifneeessary);,- . -j
FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21Remarks) 0 ft. C�0 ft. G
4.Date Well(s)Completed: 12I {I4 Z.3 Well ID# /01 c 1 q p tt' i f9 o R• (ai 1I E f e (b Gk
J
ft ft.
a.
Sp L Local idr. • e I
n Facility/Owner Name Facili ID#(if applicable) ft. ft. 3 1
q$fi Fta( Run I . Ataht e_s�x ft. ft. - 2024
Y {
1 ft. ft
Physical Address,City,and Zip gyp '°
Nct S I II.RE . 4,i0 M$1. 'i4.., .1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N W i : as $ t /1- (a 1cf( 3
6.Is(are)the well(s): I9'Permanent or OTemporary S' of Certified Well Contractor Date
_� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ti�vo 1SA NCAC 02C.0100 or 1SA 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-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: 1 v 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4)200'and 2@100')
a0 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 cnnetrneHnn method: q I r r 6+-4 t(7 tee_ v__♦v_. _c.._ ...__a n_ _r _. n__ �_ __r.� ..__111 n r A e
(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) i
I0 Method of test: h� Permit Program,1611 MSC,Raleigh,NC 276699-1611
It7
13b.Disinfection type: 11-1-11 _III.'II. lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018