GW1--04567_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractorrft5P )Infor ation:
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
r' 1 J 1 AR. R.
NC Well Contractor Certification Number i5.:0I1 rER'GASING(for:multi tasted wells)OR LINEA'(ifap 1(cebh)` ;-s
f F ` PlArAt
FROM TO DIAMETER THICKNESS MATiERIAL +� ,/A]11'�o ��I ft. ft. j i fq in. , I fJiI aLVIh ( ..ei)f,
Company Name 16 INNER C N FOR TUB IFINJG(geothertalclosedloopyi.._. -...*,-,7,.,--.,-t-.. .:,....-.
2.Well Construction Permit#: ° Lv 0 3 31 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le UIC,County,State, Variance,etc.)
R. ft. in.
R, ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM �T]O MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. o ft. k lefriv ACC( I '11
ft.❑Monitoring ❑Recovery _ R. b
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.pACK(if,app[ictitb1 . -. ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Stormwater Drainage ft. ft.
❑Aquifer Test g
❑Experimental Technology OSubsidence Control R. R.
❑Geothermal(Closed Loop) ❑Tracer 211.;DRILLINGLOG(attacL additional iheetsifnecessaryy'"
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) n ft. '� ft.
G'Q
Well ID# /0 ft' 5p R. ga A do .l v rie.
4.Date Well(s)Completed: I
�
Sa.Well Location:
S o ft. �f o o ft . gr./mit, rock
;
1f P°(S ft.'i•!V Facility ID#(if applicable) R. R.
Facility/Owner me R
pQ Z' � r•
51 33 1 i 1` ft, ft.
R ft. ))'� 3 ' �74
Physical Address,City, t�i u d Zip
/61h611S1 2,6 35 05 9_ 21;R>MAAIC$;- �1 r,t� {3xi�" . .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiflcatio ' � �
N W , ;14 j(g-' " " I J2 - ir Si lure of Certified Well Contractor to
6.Is(are)the well(s): ll'Permanent or OTemporary
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 4. 15A NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 01 remarks 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 Dosed-Loop Geothermal Wells having the same (add'See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1-1 `' `" (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and IQ100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ?NO Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.)I Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: cur- r o 4 "lei 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
`� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) .D I)?
( Method of test: 71
13b.Disinfection type: 11 I r\ Amount: i 1 '-b
North Carolina Department of Environmental Quality-Division of Water Resources .Revised 6-6-201 S