GW1--05278_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well
ContractorInformation: IA. .. Jtif,n elelL / 1,,,,.., 12,, 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Zo3‘ ft. ft.
L/o ft. Ir.
NC Well Contractor Certification Number
Un� 4 ,4 -e-1/ r,//N 15.OUTER CASING(for multi-cased d3 OR LINER(if ap Itcabte)
N/L!// l/ r(/l/ (T LFROM TO DIAMETER THICKNESS� MATE.AL
Company Name
V '!�,, jL ft 64 In. • L�.� I 6
3 , , 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Conroy.State,Variance.etc.) ft, ft. in.
3.Well Use(check well use): rt. ft. In.
' Water Supply Well: ' 17.SCREEN
❑A 1CallUnll :FROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
❑MunicipaVPublic ft ft. in.
DGeothennal(Heating/Cooing Supply) O.Residential Water Supply(single)
ft. ft. in.
❑IndustriaUCotnmercial Cl Residential Water Supply(shared) -
18.GROUT
❑17Tigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: et ft. 30 ft. 1���pp
jd ji'_m__ rou r ca
❑Monitoring ❑Recov ery ft. ft.
Injection Well:
uiferRechar a ft. ft.
❑A
4 S ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Ceothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO I DESCRIPTION(color.hardness,soil/rock type grain size.etc)
u © ft. ,o rt. r Jl,, t.J✓t 5�K 4�
4.Date Well(s)Completed: 7 -Z " Z- / Well ID# 2.0 It. 4/32 ft. li C r�
5a.Well
Location: Z,'3 ft. z go ft. //1/'/-J
" "e /-G " Loc u � ft. ft.
�©
/ aw' /G�
Facility/Owner Name /// Facility/1D#(if applicable) ft. ft.
3< g !Y/a>2- !7 !/ A/�.Pi/0/ct,//•e ft. ft.
(JI t ,.-s f�
physical Address,City,and Zip :-
ft. ft. ` `ot` ✓ c_
571a.,-74 / / ic 1/_ 27 21.REMARKS 6
County U Parcel Identification cation No.(PIN) 0 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1n/#?t r,'i::r., i --
(if well field,one lat/long is sufficient) 22.Certification: /
50 3 2 94/3 N Fa 5-30 26.
W , 4...4/
�_� 4/-•Z -ZS/
Si.Is(nre)the well(s): t rmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing(his form.1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 111:46 154 NCAC 02C.0100 or 154 NCAC 02C.0200(Yell Construction Standards and that a copy
If tins 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 farm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I 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: Z 'Y© ft
Formtdnple wells list all depths ifd#7bee„t(example-3@200'and?(a�1007 ( ) Submit this GW-1 within 30 days of well completion per the following:
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.rise"+" D (ft) Information Processing Unit,161't MSC,Raleigh,NC 27699-161 7
11.Borehole diameter:
�," (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
�/� f Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: fGdYec% 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
•
13a.Yield(gpm) Permit Program,1611 MSC,Raleigh,NC 27699-1611
IC) Method of test: .�/
13b.Disinfection type: %/ !;T?" Amount: '3 44}-e