GW1--05965_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
' -;V, '� c \may
14.WATER ZONES
Well ConttactorNa a FROM TO DESCRIPTION
��75-4( Ids iL {l5 rt Z, Gi"
NC Well Contractor Certification Number 1� ft. �� ft. `� ���.1
15..OUTER CASING(for umnlli-cased wells)OR'LIN' ER(lf ap r Gpble):.
l,) - FROM T - - •n11\It 1ER'n' 1NICI N S \t\�I'ERIAL
��,,s� : e\1 ��11�1 i�.� t�. � it. .hW � to rat..4--4
Company Name . - - ,I,} • �b ': .: i n ' ril- �Vf✓
t i , •16.INNER CASING OR TUBING(geothermal closed-loop): _
2.Well Construction Permit#: 4 D'�'�-) FROM TO DLt3IETER TIDCIC'ESS MATERiAL
List all applicable'well construction permits(Le.UiC,County.Stale Variance,eta)
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
•FROM TO DIMMER SLOT SIZE TIICI.'N'ESS MATERIAL
- ----['Agricultural . ----DM icipal/Public - -- --11.--.-_it "r"'in.- - -
❑Geothermal(Heating/Cooling Supply) "B:Residential Water Supply(single) R, ft. in.
❑IndustriallCommercial ['Residential Water Supply(shared) 18.GROUT
Ulrrigation ❑Wells>100.Q00GPD FROM TO - MATERIAL EMPLACEMENT METHOD S.AMOUNT
Non-Water Supply Well:. R_
[monitoring .. � � ft. �O �1��R�� �����
❑Reeovety - tt: ft.. . ,
•
Injection Well:
n. rt ..
['Aquifer Recharge ' `• ['Groundwater Remcdiation --
19.SAND/GRAVEL PACK(if applicable) .
['Aquifer Storage and Recovery .['Salinity Barrier -- - FROM TO MATERIAL EMPL.ACE\SEVTMETHOD
['Aquifer Test UStormwatcrDrainage R• • ft.
❑Experimental Technology ['Subsidence Control ft iL
['Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets If necessary)
['Geothermal(Heatinc/Cooling Return) ['Other(explain under#f21 Remarks) FROM TO DESCRIPTION(color,hardness so0/trocl.ppe grain size,etc)
2 (� f 'h�V' U R- it ft 'red Gla4 _
4.Date Well(s)Completed: I 1p•---a-1 Well TD# 11 19 al 40 ft- (0?J• n hc©1� coCK w/ I� '(t1�
5a.Well Location: (03 it.
I. -
`25 Vei l
- ,Aec\' c 0cK ,
\ALLX'C.j CoOmh' it tr. i
Facility/OwnerNeme Facility IOu(if applicable) IL ft.
it n
Physical Address,e City,and Zip {�
\ l t�6I el fiq 31p 000733�f 21.REMARICS OCT0 9 20L4
County Parcel Identification No.(PIN) Ir;`- ,,„., -r, r r.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �"�'�`'" "emu
(if well field,one fat/long is sufficient)
22.Certification:
36„' a317t N ` e. 33e5 w - . f0 ^1^ ay
6.Is(are)the well(s): l ermanent or ['Temporary Signature Certified Well Contractor Date
l Ai'signing thisibrm,thereby certify'that the well(s)was(Were)constructed in accordance with
7:Is this a repair to an existing well: ['Yes or l!No 15.I Arceld 02C.0100 or 15.4.1VC.IC 02C.0200 Well Construction Standards and that a copy
if this is a repair,.fill out known well construction information and explain the nature tithe of this record has been provided to the well owner.
repair under#21 remaril section or on the back of this form. -
23.Site diagram-or additional well details: -
S.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 paces if necessary.
drilled: I •24.SUBMITTAL INSTRUCTIONS, . •
9.Total well depth below land surface: I 65 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(0200'and 40001
24a. For All Wells: Original foam to Division of Water Resources (DWR),
10.Static water level casing_
u. top of casing: t� (ft-) .Information Processing Unit,161�7 MSC,Raleigh,NC 27699-1617 .
if water level&above casing'use"+" ' _ • - .. o - - -
II.Borehole diameter: (in,) 24b.For injection Wells:Copy to DVWWR;'Undergiound Injection Control.(NC)
'\� Program,1636 MSC,Raleigh,NC 27699,,-1636 .. '_; ',
12.NeII contruction.metpush [ x( f C�C 24c.For Water Supply and Open-Loop.Geothermal Return Wells:Copy to the
(i.i.auger,rotary,cable,direct push,etc.) 1 county environmental health department'o-the county where installed
FOR WATER SUPPLY WELLS ONLY: A 24d.For Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a..Yield(gpm) 10 Method of test: r k'c Permit Program,1611 MSC,Raleigh,NC 27699-1 61 t
L
13b.Disinfection type:40C \L� (r12 Amount: \ D 02,e 1,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S
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