GW1--05272_Well Construction - GW1_20240906

VYLLL 1..U1 1KUl:11UN KECUKJ(UW-1) For Internal Use Only:
1.Well Contracttj Inf rmation:
l Ai....&ei1 L/list_.' - k !�1 C,6 14.WATER ZONES
Well Contractor Name _ FROM TO DESCRIPTION
/ ft, tiZif-
/ ft. rt.
NC Well Contractor Certification Number /�
/ / f/I!/ 0' 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Z. . K/!/s I FROM ' TO DIAMETER THICKNESS I MATERIAL
Company Name ! !/� y f1%�ft. (l/e/ ft. .Gr in. ,z 50 I I�//J
/ VC
y 16.INNER CASING OR TUBING(geothermal closed-loop)
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2.Well Construction Permit#: C' -7 � f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.County.State.Variance.etc.) ft, ft. in.
3.Welt Use(check well use): ft, ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft R. in.
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❑Geothermal(Heating/Cooling Supply) ClI sidential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO T�TEERIIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. L'-' ='"`ta"tt _
El Monitoring ❑Recovery ft. rt.
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, ❑Stormwater Drainage ft. ft-
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES PTION(rotor,hardness solUroclr type grain size,etc.)
L/ 0 ft. /a ft. ' t-,/
71�4.Date Well(s)Completed: �"/9 Z%y �ell ID# � ft 50 ft. t, h 5
5a.Well Location: :.z 30 ft• l c-/ It je.G _SX-4�
Je// ZG�td P jC.12141:DCV‘i ft. 74 Oft' )) 11
Facility/Owner Facility ID#(if applicable) ft' It.
L/ r-
Physical
�Address,city,and Zip J0 ft. ft. c �+ Y
6%ir/Os"1 �;-0 9d-Of J 21.REMARKS J E P V Z024
County Parcel Identification No.(PIN) IrAO:Tlsir'.F el ,er.-,,y.4 1 l flit
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `C° lt"�'
(if well field,one latllong is sufficient) 22.Certification:
9.5q9*."-- 4/ N7'l/ W
iii.. .--_____. "'IT'"Z42/
6.IS(are)the well(s): UPlrrmanent or ❑Temporary Signature of Certified Well n or 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 IlFio /SA NCAC 02C.0100 or 1SA 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
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: R (00 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd different(example-3@,200'and 2(§100')
10.Static water level below topof casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use/" " (fl) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: h-%. (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /Ct�74 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
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13a.Yield(gpm) Method of test: .ill Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: r'7 Amount: _3/•" s