GW1--05239_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW_1)
For internal Use Only: I
1.Well Contractor Information: •
keLi.r A...ik / 6-ic, ACv
14.Well Contractor Name
FROM TO WATER ZONES
�^ FROM
w36 ec ft' ZgOR.I oesearmON
•
NC Well Contractor Certification Number ft.
/ ,q///s r i // 9 l/ RR CASING(for mull-aged Well OR LINER If ap able)
I� / Lt/�i /f FROM TO DIAMETER 71tICIQtESy �
Company Name �"`b -></i5."' 7�l R 6%5g `°' ?10 //
2 Well Construction PerT4dt 0:�iNA—W e—ZpZ,3'QO �F; It INNER CASING OR TUBING(aeotMkmal elared.fo°p)
TO nuarzrsR THICKNESS MATERIAL
-
Ile all applicable 41111 eonrtntctioepeau(le.U!G CormN,Stale.Yartancc,arcJ R. ft In.
e 3.Well Use(check well use): • ft. R. la
Water Supply Well: 7T.SCREEN -
IMMO=
°Agricultural DMu ci FROM I TO I mAM1ETER aLOTSIZE MAT@IAL
—Jtp paVPOblic rt. It. In°Geothermal(Heating/Cooling Supply) taResidential Water Supply
❑loduslrisUCommercial pp y(single g ) R. rt. to
°Residrntiel Water Supply(shared)
Dlrrigation Ill GROUT°Wells>100,000 GPD FROM TO MATERIAL RMPLACEMErr NETRODA AMODNr
Non-Water Supply Well: R R.
°Monitoring ❑Recovery
Injection Well: ft. rt.
°Aquifer Recharge °Groundwater Remediation R• It
°Aquifer Storage and Recovery OSalinityBarrier 19.SAND/GRAVEL PACK(If apdiable)
DAquifaTest FROM TO I MATERIAL �- EMPLACEMENT METHOD
°Stotmwaler Drainage R ft.
°Experimental Technology °Subsidence Control rt. R
°Geothermal(Closed Loop) °Taco
20.DRILLING LOG(much additional Meets U eeceuary)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Rerun lea) FROM TO Dascmtrnon f e..doe,.,.,wr.na t,pa Qaha flea,
G m C7 R• ma)
4.Date Well(s)Completed:y/' 'ZH 't r _ 1 C r
7 Well 1DR 03/�C R. �7�'c^� R. rib O) GI r^SB n 1C�
Sa.Well Location:r f q,. 7d R O v fL / /I i I
a✓kl G A.,t •�. LL L... ,1in� po R ` R 17-0h5iffes1 Siartf.-- rvi,4if
Facility/Owner Name v P
Facility MN(if appliable) ' R 560 R, �I
5g3o A . l sl(SfaN�^�!(L� s P x
/aJSJ/ ✓LJ+ R R
Physical Address.City,and Zip ft. ft. -
•
(./e. ✓✓fir S 21.REMARKS • • •...
CountyParcel ldantifatlon No,(PIN) S E P ) ZCL d 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: T Wive!!field,one ht/lung is sufficient)
22.Cerdfication:
35e 3S�6ySd
S'dey?7S�3 � �,r ,:t ,r�..
6.Ware)Um well(s):G7P€rmaoemt or OTempOrcry Srgrenae of Certified Wall7l�ltictar
fe .. _
7.A this a repair to so existing well: ❑Yea or By signing this form,l hereby certify that the werl(sl mu(Awe)constructed In acco,eiance Pea
o ISA NC4C 02C.0100 or 15A NCAC 02C.0200 Weil Construction Standards and that o copy
Obis is a repair,fill ma Anmm well enutrucetee ly er,,fon and explain the nature of de fthu ruord hero been providd to Mewl!orener.
repot,under Ill rereads section or an the bock ofrha form.
23.Site diagram or addxtlonel well details:
8.For Geoprobe/DPT or Cloned-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only l GW-1 is needed.Indicate TOTAL NUMBER of wells (add'Ste Over'in Remarks Box).You may also enacts additional
drilled; pages If necessary
/ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9CC (ft.)
30
For eralaple rwla list ell depths((afferent(erne p!s..3f�200'a 261.1 Submit this GW-I within days of well completion per the following:
°V
24a.For All Wells:Original form to Division of Water Resources(DWR),
10.Statle water level below top of casing:ff twat level a lamer casing Are"+" (R-) Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
11.Borehole diameter. 6 7'6' fie,) 24b.For Intention Wells:Copy to DWR,Underground Injection Control(]UC)
12.Well construction method: Zliet✓� Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,roomy,able,direct push ern) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
A • 24d.For Water Weds producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 50 Method of test irg.,/ _ Permit Progrrrm,161111 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: y7i1/ Amount: 3/ 'et is