GW1--05304_Well Construction - GW1_20240906

•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ke.141\,(1 Be,‘ C. JtJ;t_, Mc....L S 0 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
--Mfr. rt.
27to 3 6 • 29,t- ft.
NC Well Contractor Certification Number
�A \ 1 1�1 l i /f 15.OUTER CASING(for multi-caseFROM TO d hells)OR LNER(If ap Ucable)
l r�J\\ J HIV e`t Zr-% \\ rs9 fL t J S ft. b f/n in. iER THICKNESS MATERIAL
Company Name J `1 f 8 PVC
i 16.INNER CASING OR TUBING(geothermal closed-loop)
{ \
2.Well Construction Permit#: - 1 e 2C FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construi<rlon penults(i.e.UIC,County,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): ft. ft. in,
Water Supply Well: 17.SCREEN
❑A cultural -FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
&� ❑MunicipaVPublic ft, ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustrialCommercial ❑Residential Water Supply(shared) 18.GROUT
irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL a EMPLACEMENT MEN HOD&AMOUNT
Non-Water Supply Well: t) ft. 2 ft. 1,l ,���i'�1
❑Monitoring ❑Recovery rt. ft. *�•
Injection Well:
uifer Rechargert. (1.,
❑A
4 ❑Gmandwater RL'mediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage n• ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heeting/Coolin Return) ❑Other(explain under#21 Remarks) FROM R0 •
TO ft
DESCRIPTION(color,hardness wturock Mee,train size etc.)
. .
�4-bA.J n G'-lt ,
4.Date Well(s)Completed: 1 S71.1 4 Well ID# /0 ft-
ft
5a.Well Location: ii SS I,\ � ((��(('�� ft. R.
7-04't5b t •Re.C1‘ LLOCLt A rt. it [� , -
fy r -f e - I
Facility/Owner Name Facility ID#(if applicable) IL rt. ♦`l.•i�1 -./ E t.-.,-
21-l1-ib �1 r-Y1 ,s R l� SEP 0 6 2024
it. ft.
Physical�� Address,
City,and Zip ,y,
`'C`o.r1 `y 'ze t�,4 21.REMARILS ln(ptfCi:w t r•r.�swa:-,�E i
County Parcel Identification No.(PIN) (yliOG
('.tlti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
35.31SS'S- N IO12E30M 1 w
�� i(r-f1-3
6.Is(are)the well(s): 1[r•Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the well(s)urn(were)constructed in accordance wit!:
7.Is this a repair to an existing well: ❑Yes or *Po ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill 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:
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-1 is needed. Indicate TOTAL NUMBER of wells (add See Over may Remarks Box).You also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,,,
For multiple wells list all depths ifdifferent(example-3@200'and 2©100') (ft) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: d / (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use '+
11.Borehole diameter:
( Underground
24b.For Injection Wells:Copy to DWR, Injection Control(IUC)
/^g (in.) / Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A-t tr �+{C,f' 7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,eta) 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
1� Permit Program,1611 MSC.Raleigh,NC 27699-1611
13a.Yield(gpm) 3C) Method of test: Prk r'-
13b.Disinfection type: Arc' Amount ` 1 A-