GW1--05198_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: �J L(�
(e /r 7cc c/rer/64t%i n j .< 3O fl 14.WATER ZONES
Well Contractor ante FROM TO DESCRIPTION
1--t&0.2 1as 130ft. ft. ) ISO 17oJ /10
NC Well Contractor Certifi ation Number
1��/� 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
'( ,T ' l u i i` Lop ( i I I . " ,,v, FROM TO DIAMETER THICKNESS 1 MATERIAL
Company Name J �t Li PI
�y [ 1 ft. CIS rt. /_ rein. ri 25 t�/�C
,^`I J 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: .11`l4 a 1'0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perm (i.e.I/IC County,State,Variance,etc.) ft. rt. in.
3.Well Use(check well use): fr. ft. in. -
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. in.
OGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft, R, in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL
EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. .2v s '
❑Monitoring ❑Recovery It, ft.
Injection Well:
ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
ui fer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
❑A
tl g OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifnecessary)
type,grain sine OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM DESCIN(color.Aarda so eas soil/rocksoil/rock etc.)
0 ft• a 0 n• 11/�RIPTIO e-CL -C. j
4.Date Well(s)Completed: 7 a‘.3/-a I/Well ID# 0 ft. 8 0 h• s'a v ,rf //e Gam/
5a.Well Loca on: R 0 R. 'IS' n. 13 7.... . G..e,r.,f
• - qS ft. aCV'. 'Z-14e f.A.a.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
/ ,Bet,n Lilt 4 d TR, ft. fL
Physical Address,City,and Zip frt. ft.
///
A 0 Le a,rl 0 Oc6 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
3s, s lc, > 3 N 8o, 5051-/ 7 w
6.Is(are)the well(s): iiirei7nanent or ❑Temporary na f ed Well Contractor pate
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 IgNo 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 remark,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
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: 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (.9
For multiple wells list all depths ifdi different(example-3Q200'and 2®100� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:_ 11� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/ Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
limier level is above casing,use +"
11.Borehole diameter: t 73 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/� Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /LO 7 ry 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:Copyto D
5 Permit Program, WR,CCPCUA
13a.Yield(gpm) a �/ Method of test: / j r' 1611 MSC,Raleigh,NC 27�99-1611
13b.Disinfection type: 14 7/T Amount:_3 pI 7(S'