GW1--04960_Well Construction - GW1_20240816

VT'r,i.l, 1.-V11a I KUL I lV1N KV L,VKCI(h.W-I I For Internal Use Only:
1.Well Contractor Informa on:
c J / ( 1- - • 'MO n(J O)ri 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
I
L.
-77)-,
LI 2_,‘,/v) ft. i) ft. �qf)a:
ft. ft.
NC We I Contractor ertificationp Number (�y� /1 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
C a-' / I I ( 1 )L" 1l// / J�', FROM TO DIAMETER THICKNESS MATERIAL.
l�/ L 1/Ol�j{{ ll ((JJ 1
Company Name "'/ R. L.�'r) ft. in. - /yd /// L
/ 16.INNER CASING OR TUBING eothermal closed-loop)
y,�f G'0 7Sf _ETS
2.Well Construction Permit# ���lv 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 Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public zu,-t ft. '7 � ft. --2 in. 2 0 /
. -
, C f! 4/L) L
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO TtRIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: L) ft. 7)) ft./ '. J /�✓.' Z / {
rY ft. ft.
❑Monitoring ❑Recove �""/
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation I
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT M TROD
❑A uifer Test 7„ ft. fL / i
9 ❑$tormwater Drainage Z 7' Z tlC1 ,` j{ya{f - 4, -7,Uk t?� G-4,.t�.f
❑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 tins,etc.)
ft. ft.
4.Date Well(s)Completed: 7/3//Z f Well ID# ft. ft. -
Vii I Location: ft. ft.
ft. ft. 1-, .�;^1
j vi L L. ::i 7---6 1
Facility/Owner Name Facility ID#(if applicable) ft. ft. A LIG 1 1! 2024
ft. it.
Physical Address,City,and Zip ft. ft.
J�:
Pt "--1- CUB (x4/0(JC) 21.REMARKS
County Parcel Identification_ No.(PIN) -__ __ •_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `,
(ifwell.field,one Iatflon is sufficient)
3 t 0 N 7 Z z) 1 7 W _ -3
�,11• � �/��
6.Is(are)the well(s):)KPermanent or ❑Temporary ( *•+ • ctor Dat
/ By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or r 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information a d 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:
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 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: //
/ �V 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: [ (ft.)
For multiple wells list all depths if different(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: I� ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" .r/, ( ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: )/,
(m) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(NC)
,f ,/ Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: n/) flu I f 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 27699-1 61 1
13a.Yield(gpm) J Method of test: ll A({�.
13b.Disinfection type: H- 7 I (�'Amount: J
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resoun.es Revised 6-6-20I8