GW1--05197_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well� Contractor Information:
't\;o ?. t ill e,r 1 e� 14.WATER ZONES
Well Comtacto Name J FROM TO DESCRIPTION
35 l � 1si 0 t� �c3 M
NC Well Contractor Certification Number 2�`lS IL
a6 s o ��M
IS.OUTER CASING(for multi-cased wells)OR LINER(if a )
�` 1 l �� FRO 1 TO \ME THICKNESS MATERIAL
e n I e � vJ J I O r I i.r n�.., I Top
i n c.,. -ill �!�
Company Name J 1 � I i tta to. _ �(3 V. t roll
11 ''\\p 16.INNER CASING OR TUBING(peother•ma1 dosed-loop)
2.Well Construction Permit#: W` _ (L 9 FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable well construction permits(i.e.U/C.Como..State Variance.ere.) H. R. in.
3.Well Use(check well use): ft. fL in.•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SI/X TIUCIC,IESS MATERIAL
❑Agricultural ❑M�unicipal/Public it. R. in.
❑ rm Geotheal(Heating/Cooling Supply) MResidential Water Supply(single) D, ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD tEAILMENT
Non-Water Supply Well: R. ft,
LIMonitoring ❑Recovery ft. ft.
Injection Well:
ft. It.
❑Aquifer Recharge OGroundwater Remcdiation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 0 R• •)-O fL (i2 t'1Gr'ri' ' ��
1'Dtr.-+ro n i�t2 P P e-.8
❑Experimental Technology ❑Subsidcn a Control ff iL
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(litating/Cooting Return) ❑ #2
Other(explain under 1 Remarks) FROM TO DESCRIPTION(oiler.hardness,saHtroct cape grain sire ese
Q, p O IL (0 IL do`! so-t1
4.Date Well(s)Completed:V-4.;?' -a 1'J Well ID#W f- , 6 p ft. e)`J fL i,,no t ram- rp 1 I
Sa.Well Location: t 80 it 1 I O R. S ea:rY\n s a1+41; pa ri)
V\P-r ry 4o,\owol I I D �' S IL ('(may 6rG f
Facility/oar Name Facility MP(if applicable) D it
ft. R. i�,-. . r ti... . '1 -,
--3-j Sc_kri4-c:+rN Pd.Wt reniroo , riC_
Physical Addams.City.and Zip 1.1 S$9 iL IL S E P •) 2 Z 07.4
/ 21_REMARKS
County Parcel Identification No.(PIN) i;
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/Ioag is sufficient) 22.C cation
3‘. 3 o y99 N -7 Se D3SSLI w _ k r 49 oe.,11, ?e,
6.ls(are)the well(s): 9f'ermanent or ❑Temporary Si or ofC red We ntractor
By signing this form.I hereby certif that the vtell(s)was(were/constructed in acronlance with
7.is this a repair to an existing well: ❑Yes or 1,4o 15,1 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under#21 remark1 section or on the back of this form.
23.Site diagram or additional well details:
3.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 1 GW-I is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I
�- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'J ft.)
For multiple wells list all depths if different(erample_3(a)200•and 2(a)100') ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �-� (ft-) 24a. For All Wells: Ori£cal form to Division of Water Resources (DWR),
If inner level is above casing.use"+ ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
I I.Borehole diameter: a (in.) 24b.For injection Wells:Copy to DWR,Underground injection Control(iUC)
Program.1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: all r i okai-y 24e.For Water Supply and Open-Loop
Geothermal Return Wells:(i.e.au r,rotary,cable.direct pleb etc.) county environmental health department of the county where installed
Copy to the
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR_CCPCUA
Permit Program. 1611 MSC.Raleigh,NC 27699-161 1
13a.Yield(gpm) 15.
I^t Method of test':" '1
/
13b.Disinfection type:t t((PQC i`O(t� Amount 1 5 02
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resonates Revised 6-6-201 S