GW1--05303_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor� Information:
�T�;IFI"f P Li 1-2-4.cif r/,&i ec/'I <Pric a 14.WATER ZONES
Well Contractor Name FROM TO DESCISn eION ,et,
W D� rt. ft. (�S) /J.5) pi Si 1 '75
ft. ft.
NC Well Contractor Certification Number
V / /y� / ��y/� 15.OUTER CASING(for multi-cased wells)OR LINER(If a livable)
4l 1I l�.L.��/ �p// K//'/Ll;n S ..7.07 45. DIAMETER ' THICKNESS MATERIAL�
Company Name I ! ft ft �J, in. A /� 5� /' e
1 5 2 52 16.INNER CASING.OR TUBING(geeojthermal clos led.loop)
2.Well Construction Permit#: G FROM TO DIAMETER THICKNESS MATERIAL
Litt all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
`, 3.Well Use(check well use): - ft. R. in.
Water Supply Well: -17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public n, ft. in.
❑Geothermal(Heating/Cooling Supply) Wiesidential Water Supply(single) ft. ft. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lnigation ❑Wells>100,000 GPD ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /) ft. n°n. 49^� ` �,�J
❑Monitoring ❑Recovery V fc o� � [/ rr ryaY s�
Injection Well:
ft. rt.❑Aquifer Recha
rge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑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,hardness eel/roek type Wahl size eta)
0 ft. a0it. ,5Ae1/ . S1-one
4.Date Well(s)Completed: �" ? 42/ell ID# ' 0 ft• J1 iirze,c tt? z,•_•7i-
5a.Well Location: +� ys ft.ft. ::OV • r d.t.e
Facility/Ownerft.
/ Name Facility ID#(if applicable)
dft. rt.1 1 0 /. j
,{�-• 6`/.ec t 7 ✓'C 1.4-)Q�l,/ rt. ft.
Physical Address,City,and Zip / n ft. t L``e L : ' 1--i
55 1"���� 1 (O r7 69 21.REMARKS. Y ,
• County / Parcel Identification No.(PIN) Ci E P 0 6 2024
5b.(if Laell titude
lvlong longitude
degrees/minutes/seconds or decimal degrees: Info;r*,lr P,,,,aeci;-,2(J
fficient) 22.Certification: o' o
J o q J N V e C < 0 W - - - ` ,:2 -.^t-/
6.Is(are)the weli(s): ermanent or OTemporary or red Well Contractor Date
/` By signing thisform,I hereby cent(that the welts)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or k9No ISA NCAC 02C.0100 or 1SA NG1C 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 beets provided to the well owner.
repair under#21 remarks section or on the back of dais form. 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
(add See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW/is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: GI (ft") Submit this GW-1 within 30 days of well completion per the following:
we For multiplells list all depths it-different(example-3@200'an 2@100')
'10 Static water level below top of casing: D ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
((roarer level is above casing.use"+^ . Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: & //3 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /r 0/4ar j 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) cdttnty 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
AlPermit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) el Method of test: i r
13b.Disinfection type:]T 7 / Amount:340in 74 5