GW1--05837_Well Construction - GW1_20241001

....:,1.1s., <.V1\1J11\V<.11V1\ 1\1`rt.V1•11(lirv-1,i t'orinternal use Only: '
1.Well Contractor Information:
%-1 T ff rred 1 t4p Ga ,'v , /7..tco h 14.WATER ZONES
Well Contractor Na a FROM TO DESCRIPTION
D o7 /j� ft. ft. 6Dl -I
ft. ft.
NC Well Contractor Certification Number
y�/t /�f �yJ 15.OUTER CASING(for multi-cased wells)OR LINER(if a liable)
mom fV• L,Nar `///S i- '/ /✓r;(l/✓7$ C• TO3 �ER THICKNESS MATERIAL
ft. ft tc, e s in.
Company 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ra bail 's OO(9 y 8 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muni ' 1/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) idential Water Supply(single) ft, ft. in.
❑)ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD " FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft �)d ft. c/39n /_ _-`-`�b/
OMonitoring ❑Recovery ft. Gi` ft. ✓ o e
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage - ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWrock type grain she,eta)
p �,/ Q ft. a O ft. e�
4.Date Well(s)Completed: / ' E 5 e JVVelI ID# Q �� s
Sa.Well Location: ► h/3 ft. /6Oft. 3/_ p G _ _ - •
v v u r -esNr °: 1,002.04aL rt. / fL ,`a+�4CP
Facility/Owner Name Facility ID#(if applicable)
0,77 fictx L;r. /f Rd ft. ft.
Physical Address,City,and Zip ft. ft.
r a �4-I r 5 ttl 21.REMARKS tI %' i
County C/ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - ,. - _
(if well field,one lat/long is sufficient) 22.Certification:
35 , Li a ,Q7.5 N gi . `1S l7 '7 W
/ 7-as-a)1
6.Is(are)the well(s): ermanent or OTemporary
p �-of C;r�red Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or VW- 1SA 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:
• 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
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: d 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I- 6/9 (f1) Submit this GW-1 within 30 per completion
days
of well the following:
For multiple wells list all depths if different(example-3Qa 200'and 2®100')
10.Static water level below top of casing: 3S (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use�"r+"
( Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 'P (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ROA:2 r)/ 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
) C' R Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gpm)
Yield .. Method of test: /9(,
13b.Disinfection type: !' TA/ Amount:...140;4 1-s