GW1--05277_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
I.Well Contractor Information: ✓
JF9 r't 72.c/ffsc /(SQL;n 0-GG�1'�(jfry 114.WATER ZONES i
TO DESCRIPTION
Well Contractor No FROM
'l( oa.. rt. R L9
NC Well ContractorCertification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if:wile-able)V, 4., /awl//S t-Ai �� � �e � e(i n i FROM ' TO ' DIAMETER ` THICKNESS MATERIAL
ZivC 4�{{ / R rt. /_ li, in. as
Company Name T ! (��� Pve�
�y/ 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: LJ c7 /(, / FROM TO i DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UiC,Conan',State,Variance,etc.) rt. It. In.
3.Well Use(cheat well use): ft. ft. in
Water Supply Well: 17.FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it, R. in.
°Geothermal(Heating/Cooling Supply) ViRfildential Water Supply(single) g, ft. in }
OlndustriaUCommereial °Residential Water Supply(shared) 18,GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. a D ft. 47esT �d �
❑Monitoring ❑Recovery ft. ft. �t�
Injection Well:
ft. —
❑Aquifor Recharge ❑Groundwater Remediation It
19.SANDIGRAVEL PACK Of applicable)
°Aquifer Storage and Recovery °Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
°Aquifer Test ❑Stornwater Drainage ft, ft.
°Experimental Technology ❑Subsidence Control rt. fL
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardnesr sollimck i7pe vain size,etc.)
O FL /8 ft. low C/ ..,
4.Date Well(s)Completed: & 7ra '-�y/' Well ID# j ^g R' ft' ilk.e; 531-e-e2L
S ell Lo ation: �/ ) 1p O0rt• `4 a C�J�
\c;ncral Lo ! , at- fL ft.
Facility/Ow rName Facility IAN(ifappplicable) ft. ft.
i:SEF:102-6-i2.
;Physical Address,City,and Zip /1 nft it.z \_ ` ( L403 / ( 21.REMARKS 0�4'
/ 11: r(p
County Parcel Identification No.(PIN) 1 NOtr' eni,.;iye,,,.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �t er��V URA
(if well field,one let/long is sufficient)s 22.Certification:ea a S N S 4 Cl // w '-ic�G.-2- -t- 6 - a !- ^y3J/
6.Is(are)the well(s): t<rmanent or ❑Temporary 1a51ofCotiiIed Well Contractor Date
By signing this farm,i hereby acre!),that the well(s)was(were)constructed in accordance with
i 7.Is this a repair to an existing well: DYes or t I5A NCAC 01C.0100 or 13A NCAC fr1C.0100 Well Construction Standards and that a copy
!frills is a repaht Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#2)reatarkl 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 l W-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: tt'00 (R') Submit this GW-1 within 30 days of well completion per the following;
Far multiple wells list all depths If different(example-3@200'and 2C)100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3 0 (ft) Infvtntation Processing Unit,161'7 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
1 t.Borehole diameter: �d p (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: R D/art/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le,auger,rotary,cable,direct push etc.) / county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinglaver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) .J
C' Method of test: 1-31 r I- Permit Program,1611 MSC,Kale gi tt,NC 27699-1611
13b.Disinfection type: 1+ Amount .3 fJ r'/1 /_s