GW1--04558_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
(Fr/c S 4A.ci rjo A 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2'7O toL , 90 ft. /be ft j
ft. ! ft.
NC Well Contractor Certification Number �1 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
544de/42 Welt br:lG'v FROM TO DIAMETER THICKNESS MATERIAL
Company Name
O ft ICI ft. •Z in. Sce y0 PPC
16.INNER CASING OR TUBING(geothermal dos -loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(r.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ()Municipal/Public ft. /OD ft 2 in. 1 2 5carlit rG4
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) Iv ft ft. in. Scar
.al/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO `MA/TERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (.7 ft .Z 0 ft' J/7/X-t„N G rariflj Peal
Monitoring ORecovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge ❑Groundwater Remediation • ,
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalmlty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
n U ft. 2 p ft. Csray , gr...., .St./' CA,,,
Date Well(s)Completed: ?�/����.3 Well ID# Za ft.
lc, ft G`4 C�a / «,/rw. .-t. i
5a.Well Location: 3 0 ft' s-p ft. S� f ,s A„„or
Ay&e,Lleet SV ft Sfo ft /46.4 Sf v JAW £t4/J./Ger
Facilitythyner Name Facility ID#(if applicable) 80
ft et O ft. 11,t
'I t,
1f&ge.0 Ai HW yl , Mae °1. 12T31b14 50 ft. ,00 ft. ttA;f_s____Coa'se .s,4y,
Physical Address,City,and Zip ft. ft.
Robc3v' 21.REMARKS - , I;
•...... •. '1... V fi.-
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J IJ 2024
(if well field,one latilong is sufficient) 22.Certification: ,.y y �._ 3
3'' it. .275 /N 79°2 j BYS .. . `_;, x
6.Is(are)the wells) ermanent or Temporary Signature of Certified Well Contractor D to
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Q o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under d21 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: /QC (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 3 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i t
11.Borehole diameter: �j (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /
iRo f.f t(� Ort iV above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
D
13a.Yield(gpm) 10 Method of test: / tiMP 24c. For Water Suunly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:___ ii rK Amount: ib 1r4IK1 completion of well construction to the county health department of the county