GW1--05288_Well Construction - GW1_20240906

rr Lill!1.ViNa Stein..t1t11Pi RECORD(GW-1)
1 For Internal Use Only: •
1.Well Contraeto/r,1 ormallon: /7 •
tH 4. i IL
if
Well Contractor Name C C� 14,WATER ZONES .
FROM TO DESCRIPTION
NC Well Contractor Certification Number N. ft.
` G 15.OUTER CASING for multi-saved wells OR LINER ifs,,licable
!L I f �e.1 l! )4 FROM TO DIAMETER THIC;NES rd: e Company Name
�• �ft. ft Ly 91 �,—/---�����
�7f in. ! C./d '/F/C
2.Well Construction Permit#: Z3 "I 7 16.INNER CASING OR TUBING . ,.,armor elosed.laa,
List all applicable well c0nsm(cNat permits(t.e UIG Counfv,Srtue, arlance,etc,) RFROM TO
. DMMI376R THICIcJ' s MATERIAL
ft. in.
3.Well Use(check well use): R. ft. --- in
Water Supply Well: 17,SCREEN
OAgriCUltural (71VIWijCipat/Pnblic nom TO DIAMETER SLOT SIZE TIllCK,vess MATERIAL,
OGeothermal(Heating/Cooling pp y) e Su 1 tom/ ft. R. in,
stdential Water Supply(single)
❑lndustria1/Commercial ❑Residential Water Supply(shared) R• ft in.
❑irrigation 18.GROUT —
C]Wells>100,000 GPD FROM TO MA1Enrwi
Non-Water Supply Well: 0 A 4 *�i C. TA :--
DMonitoring i418NTbIET$OD&AMOUNT
OReaovtsry
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation ft. R. —
❑Aquifer Storage and Recovery °Salinity Barrier 19.SAND/GRAVEL PACK Cif apiaRcabte)
❑Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
OStornawater Drainage R. ft.
°Experimental Technology ❑Subsidence Control
R. ft.
OtJeothermal(Closed Loop) pTracer
20.DRILLING LOG(attach additional sheets ifnecessary)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROMTO DESCRIPTION tardoces nil/rockf[. /5 R, type,grain srrrr,ere)
4.Date Well(s)Completed: 7'J�Q--2 / Well� /5 it. /l� fr. C/g I
Se,Well Location: I :,� <iy R, Imo ft.
7.2t.aititc,.
�ei5SPc cL �// ft. ft.
Facility%Owner Name (FacilityyID#(ifapplicable) ft. R. / _
6710-'h—i1l 411, f 4-) Ce f. ft u �i 1��'
physical Address,City,and Zip 7 �^ ft. ft. �'t- ' f I 0 L U l4
nicb—, c/6o4�3DJF� A zl.REMARKS •
(/7
Cotmty Parcel Identification No.(PIN) tr.t;, »,
r,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iadlong is sufficient) —
�.�V/30� eon 22c z/ / 22.Certification:
N f� W . �/, •
6,is are the wells. p ry / ���`ra
( ) ()' [:permanent or C7Tem era Signatureof entfied Well Contractor (....30....z.v
�,,( Be signing this form,I hereby certify thar the well(s)was was(were)constructed to accordance with
7.Is this a repair to an existing well: ❑Yes or glINO 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,f111 out Anottvt well construction information and explain the nature of the of this record has been provided to the well owner.
, repair tinder 1121 retards section or on the back of thisfomt.
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 pageto provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled;
r�� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ii0C,/ ( )
For multiple welts list all depths ifdifferent(example-3(a)200'and 2©100� 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,use"+" {") Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 //$. (in.) 24b.For Infection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 71a
(Le.auger,rotary,cable,direct posit,etc.) 24e.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:
24d.For Water Wells pprodactng over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) .3 _ Method of test -- Permit Program,1611 MSC,Raleigh,—NC 27699-1611
13b,Disinfection type: // 7 Amount: .3/5 1I $