GW1--05244_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1. T Well
Contractor Information: /
. 1 / Fc / !!7 e r i/l?0.11 i YI V QC II s D/7 14.OWATER ZONES 14 DESCRIPTION
LWell Contractor 1,1(/
R. ft. 7 R'5
D Z ft, ft.
NC WeI//I Contractor Certification Number' ) p� / T 15.OUTER CASING(for multi-cased wells)OR LINER
(If a livable) /
FROM TO
ETER
L. s�/.c_t/1;_5 Wl�i/ cizf . .l��C / ft. 't�/q fL [t7o+in. O07 5-
THICKNESS MATERIALp V, L.
Company Name / CJ O
// �/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: /ll, '' (2.''7 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance.etc.) ft• ft. in.
, 3.Well Use(check well use): it. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. It. In.
OGeothermal(Heating/Cooling Supply) mftteside ntial Water Supply(single) ft. fL in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. a o ft. ,G(On4,2":4 p _ /
❑Monitoring ❑Recovery ft. it
�K_�C
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test. OStormwater Drainage IL ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROMO-�H TO DESCRIPTION(color,hardness aolLracle type grain size,etc)
L, 0 fL /C F o R' P c .
q
4.Date Well(s)Completed: g ! -a2"I Well ID# /o fL y 07 ji ft. t. ,�
Sa.Well Location: /J y h' /t IL ✓J/ 1 `c (
acility Owner Name Facility 1D#(if applicable) fL ft.
/‘oa ,29uJ�-P_1) R. ft. ft. i ,
Physical Address,City,and Zip
It. ft.
i.�`I G cr4s 21.REMARKS ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35. Va38a N 80. 3811ail W � _ 8 - '7 -a1-/ay/4x,Contractor Date6.Is(are)the weli(s): anent or ❑Temporary
l iatt erf ell 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 vro I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill out knotwt 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: (� (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
L' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f 17 D (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t@200'and 2@100')
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
�� (it) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 4 Yli (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /[/)i-et r . 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,
1 Permit Progtam,1611 MSC,Raleigh,NC 27699-1611 CCPCUA
13a.Yield(gpm) 0 3 Method of test: /4! I-
13b.Disinfection type: 14 / /(7I Amount: pi n+s-