GW1--05329_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
P/i111 0 IQ. S/� 14.WATER ZONES
f FROM TO DESCRIPTION
Well Contractor Name
1S-'f/ !%S IL /9$ n_ ,0�®�
I
NC Well Contractor/ Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
e ii1 /�s n I) , /,/ j)l y r in C I FROM TO
-q DIAMETER THICKNESS \t.\"rF. lAL` Q I
Company { Oa �IJL/ �f h ��"E D c��,n $� f D IGL'P C1t4C
p I6.> R CASING OR TUBING feothermal ceased-3)
2.Well Construction Permit#: 0(t�p�S FROM TO DIAMETER i Tlll('kNESS MATERIAL
List all applicable well construction permits ti.e.U1C County.State.Variance.etc.) R. it. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN AI 14-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public Q. ft. in.
❑Geothermal(Heating/Cooling Supply) PrResidential Water Supply(single) R. n. in.
❑lndustriaUCommereial ❑Residential Water Supply(shared) 18.GROUT
❑Irritation OWells>100.000 GPO FROM TO ArEnu.. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O R. R.
tli 1
AD ft.
.
UM nritoring ORecovery ft. ft.
Injection Well:
a. rt.
❑Aquifer Recharge ❑Groundwater Re mediation
19.SAND/GRAVEL PACK(if applicable) "I A—
f_lAquifer Storage and Recovery ❑Salinity Barrier FROM •O MATERIAL EMPLACEMENT METHOD
DAquiferTest ❑StormwaterDrainage ft. R.
LJI:xperimental Technology ❑Subsidence Control ft. rt.
flGcothennal(Closed Loop) ❑Trager 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Htating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION eerier.Aanlrwss snifrock type.�:a size.etc.)
O R. ft. ..
Q _ �.r� (�.�2. c� srs�.P
4.Date Well(s)Completed:� � Well ID# ��4 O�S a O-tL• 40
ft- J,t,-t er„5
Sa.Well Location: ((( /D ft. A ft. '6 /+ _ "
f7 iL ft. ut7ts�S
Hnie V-f kit rU i^aSci411
Facility Owner Name Facility IDS(if applicable) 7L n. __
��►if• —.,..
3(, .14„.,to(4 F CAkD 2 Q ui1�n)GA75J7 ft. St P ` 24
Physical Address.City.and Zip �^ fL rt. S 6 2°14
V e Ile_ /O A 000 6 t97 9 4p 21.REMARKS If
County Parcel Identification No.(PIN) DoN..ee"^
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 j
(if well field,one latilone is sufftciem)
cario if
6.'stare)the well(s):�Termanent or OTemporary aitmattm of ern ed a Contra fr Date
Hy signintg this fOrm.I hereby certi/i•that the trellis)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11JVo /It A'CAC 02C.010(1 or 114 WCAC 02C.1121N1 Well Construction Standards and that a cony
if this is a repair..fill out known well construction information and explain the aattrnc of the. of this record has been provided to the well owner
repair under 0./I remark;section or on the back o!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 I 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: 442 5— (ft.)
For multiple tells list all depths fdilierern ri;ranrplc-3fu/200•and 2(a?l00•► Submit this GW-1 As'ithin 30 days of well completion per the following:
10.Static water level below top of casing: oR 0 (R) 24a. For All Wells: Original form to Division of Water Resources (DWIO,
If utter Jere!is above casing use"+r(" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1 6 1 7
11.Borehole diameter: b (in,) 24b. For Injection Wells: Copy to DWR,Underground injection Control(WC)
nn
- y�7E Program, 1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: 1 II k 62o /-14 Y' 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 MIN: 24d.For Water Wells producing over 100,01)0 GPD:Copy to DWR.CCPCUA
/ i
Aietliod of test Permit Program 1611 MSC.Raleigh,NC 27699-161 I
13a.Yield(gpm) i[ 0
13b.Disinfection type:de
/si Amount 7,
O O .
Form(W-t North Carolina 1)eparntem of Environmental Quality-Division of Water Resources Revised 6-6-201 S