GW1--05189_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
.J Ffrey 'Tact/,er / fin",,i.!'1 girt ,e 14.WATER ZONES
Well Contractor NameFROM TO DESCRIPTION
Li-(o O , ft. ft' / Of ,2 /O� (2,(1 ~l0
ft. ft.
NC Well Contractor/ /��Certification Number 4�f 1 15.OUTER CASING(for multi-cased wells)OR LINER(It ap Ikable)
V C. !;1 G(,///S L1�e ff L!/'i4L .-1!� sA C / ft
/ + ^FROM TO DIAMETER THICKNESS MATERIAL
Company Name / /R/ Y tn. 4015 Pe c.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: " a.o�3 r'll�O j 31 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) rt. ft. In.
3.Well Use(cheek well use): R. ft. in
Water Supply Well: 17.SCREEN
:FROM TO DIA.METER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. lt. in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) R ft, In.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO gMpATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' .20 ft' ueri fro nil1. ,O e.a re e✓
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft'
❑Experimental Technology ❑Subsidence Control ft• ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCAI ON(color.hardness,son/rock type,onto size,etc.)
❑Geothermal(Heating/Cooling Return)!� ❑Other(explain under#21 Remarks) O ft. Oft. t C/
4.Date Well(s)Completed:oC pc
- -al.-,Well ID# e2 O ft. '0 ft' P- G...�
Sa,Well Location: //+!�� �i 0 ft* 11 a . p u� e /" t'd .
a L w..�CJC� - //?fL 300ft. ��. C,�'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
L6z X f 17 e h etrd- Rd ('ncorcodvsL.
Physical Address.City,and Zip ft. ft.
_r -, C4'C-1 46 57 1( ^31 21.REMARKS.
County ( Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Int/long is sufficient) 22.Certification:
3S.5(15/61 N V o , 8o255 8 W 9 � .�� �-, -.2 Li
6.Is(are)the well(s): I6rmanent or ❑Temporary b ofC ed 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 rflivo 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair-Jill 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 TV-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 00 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(cremate-3®200'and 2@100')
35 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 27699-1 6 1 7
If water level is above casing,use"+"
! 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: %Ts (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: fie 7L01.r y 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
f� T/� r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I t it Method of test: ! l r
13b.DIsinfection type: ti -7/4 Amount: 3 / i fl f s