GW1--05838_Well Construction - GW1_20241001

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1.Well Contractor Informatiion_ // Weft #�
S�FFrey leJ) COY'J/ �js'l'J LJ aCe!�]�f017 14.WATER ZONES
Well Contractor Nam FROM TO DESCRIPTION
Il�o� ft. ft. // v a00 � s
R. ft. t0
NC Well ContMractor Certification Number cy� •
15.OUTER CASING(for multi-cased wells)OR LINER(If a Ikable)
V, 4-, 7' �ll�,S �LJ .</ U/-i Ll!n �/f/c. FROM TO DIAMETER THICKNESS MATERIAL
/ii / ft. t 1 `� ft. / in. ocS P Vc
Company Name T•-+ g �
CI-Ilk-WE 1 ', i ko, 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: - t-� I�1 Cal lam. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits .e.UIC.County.State,Variance,etc.)ii�� �` R• ft. in.
t 3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
` FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it. In.
❑Geothermal(Heating/Cooling Supply) lilcesldential Water Supply(single) ft, ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. '1 a R. C y„^Tz l __ r
❑Monitoring ❑Recovery ft. ft.
o� l"-" ' Ot-wwl
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. it.
❑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#2 i Remarks) FROM TO DESCRIPTION(robe,horaaess sonlreck type,grain sift etc.)
O rL , 4e4.
4.Date Well(s)Completed: CI-17-a2f Well ID# 01 p it. 413 ft. e ..S-e_..
5a.Well Location: :-i 113 R- 3 Q& V L e S C
rt. R.
��ws - Mil IL ft.Facility/Owner Name Facility ID#(if applicable)
'7-5o g Tot„ FLr r/' 2c�• ft.
Physical Address.City,and Zip ft. ft.
C_ /_ cc/r14.1
21.REMARKS `1
County 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 . 3 / Sa6 N 80 . 1/65 UI.Z. w ? , 1 7-aii
6.is(are)the well(s): 1rmanent or OTemporary _ °tigWell Contractor Date
By signing this f/orm,i hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or e1446- 15A NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fell 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: L7 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `3 a 0 (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths i(dierent(example-3©200'and 2(0100') y p
10.Static water level below top of casing: 35 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing.use"4-" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (o //g" (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
,L Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: / G 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
13a.Yield(gpm) S. Method of test: //a/ r' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H 7-hi Amount:a, r I)1 J-S