GW1--05185_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
..t F toy 7-Lc.c.!etPor-/ 6 c',v%t1 CTa-C/5-5 b 14.WATER ZONES
Well Contractor)(erne FROM TO DESCRIPTION
(� O tr. R. ��� / 0) 3,5'-
NC Well Contractor Certification Number n• ft.
P. 15.OUTER CASING(for multi-eased wells)OR LINER(if ep lktible)
�•QQ// m/`l/1 s 1-fi e 19 f I , FROM TO l DIAMETER
/ ' �i rt ��� I THICKNESS MATERIAL
Company Name s / ft. LJ ci ft, /_ /� -1
/ 16.INNER CASING OR TUBINIs, A to o �v c
2.Well Construction Permit#: . 00/113 7s 1TEothermal closed-loop)KNSS
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well caaslt•(retial permits(i.e.UIC,County,State, Variance,etc.) ft.
fit. in.
3.Well Use(check well use): ft. ft. In,
Water Supply Well: 17.SCREEN
°Agdcultutal FROM TO DIAT1ETEk SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public R. ft. In.
°Geothermal(Heating/Cooling Supply) �idential Water Supply(single)
❑Industrial/Commercial n ft. in,
❑Residential Watec Supply(shared)
18.GROUT❑lrrigatian
❑Wells> 100,000 GPD FROM TO MATMAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. U tf, p.�
❑Monitoring N-4-t llu
D �tp�
❑Recovery ft. ft. !-
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft
°Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
°AquiferTest. ❑StormwaterDrainage ft. ft.
°Experimental Technology ❑Subsidence Control
ft. it
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM DESCRIPTION(color.hardness,so Wrack
aft. J ft. (� hPe e+a7n slu.etc-)
4.Date Well(s)Completed:4,-i 3--d!t� Q /
Well ID# ) ft. , , ft. dr`r (
Se..Well Lo ation: / y f ft 9
60t -
r4 R.
Facility/OwnerName Facility ID0(if applicable) Ir. ft.
/3306 GrP,Mr.Sf V, . fc
Fp .'
Physical Address,City,and/Zip ft. ft.
/r) ccis,Le11 IJLe et", /11 "' 3 - 13 21.REMARKS
County S Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient)
rJ 22.Certification:
a 35. a. Li u i N IC 4 6 a1- ! `7 e., w
6.Is(nre)the well(s): •Permanent or °Temporary 5t a e of rtlHed e17 Contractor / 1��
Dato
BBy 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 IZIPe 1SA NCAC 02C.0100 or 1311 NCAC 02C.0200 Well Construction Standards and that a copy
If dris is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the welt owner.
, repair under tit l remarks section or ors 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 I GGW-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! ii 0 0 (ft.)
For multiple wells list all depths if different(example-3@2 0'and 2©l00`) Submit this GW-1 within 30 days of well completion per the following:
�- 0 (fit) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
If water level is above casing.use"+" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter: 4 �$ (in.)
Program, 1636 MSC,Raleigh,NC 2 7699-1 63 6
12.Well construction method: a 7L4,rY
(i.e.auger,rotary,cable,direct push,etc.) 24e.For Water Supply and Open-Loop Geothermal ReturnWells:Copy to the
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) ] Method of test: i9 Ir r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 147-y<71 Amount: 3 Q i i1 As-