GW1--05972_Well Construction - GW1_20241009

v rI WELL CONSTRUCTION RECORD (GW-1) For internal Use Only: '
1.Well Contractor Information: 1
Q ` A I
! ILr 1 e- L 1'.f�►ks/�L� 14.WATER ZONES - I 1 t
Well Conrr a for Name `// FROM TO DESCRIPTION
.2c•-0 ft. As-3 rt. 3.4-t1 c9P" --
3s-ct--( 5 8 q rt. . 6 9i.n. trii /11-
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased:tells)ORLLNER(if ap licable)
I ��qq I FROM TO DIAMETER I TIRO:NESS .MATERIAL
Company Nand ` ft. 6 ft. to t/f in. 6 QoT t O l�G
� _ 16.INNER CASING OR TUBINGtseeiihermal closed-loop)
2.WelI Construction Permit it: 5 43 33.S FROM TO DIAMETER' t THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC.County.Stale.Variance.etc.) It. it. i in,
3.Well Use(check well use): ft_ ft. in.
17.SCREEN '. •
Water Supply Well: FROM TO DIAMETER SLOT SIZE 1 THICKNESS 1 MATERIAL
❑Agricultural ❑MunicipaliPublic ' ft. -ft. in.
❑Gcothcrmal(Heating/Cooling Supply) NResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) I
13.GROUT
❑Irrigation ❑Wells> 100.000 GPD FROM TO MATE I ESIPLACEMENT METHOD SAMOUNT
Non-Water Supply Well: 0/!� It. A 0 fL ,)pj �� Pt 1I
GMonitormg ❑Recovery ft. . ft. 7- c(
Injection Well: - - J
ft. D.
❑Aquifer Recharge ❑Groundwater Remcdiation /�
I9•SAND/GRAVEL PACK(if applicable) /fr.
❑Aquifer Storage and Recovery ❑Salintsy Barrier FROM TO I MATERIAL EMPL:ACEMENTMETHOD
❑Aquifer Test ❑Stotmnater Drainage R. fr.
❑Lxperimental Technology ❑Subsidence Control ft. ft. I
1 '
LJGcothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additieinal sheets if-necessary)
❑Geothermal(lieatine./Coaling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION(color.Aanlness.soil/rock ape.Brain size,etW
/ to ft. a� R. �•r s
ti �t1dY s©;I
4.Date Well(s)Completed: O 9A6/o o Weil TDr go S 33 S- ao ft• ./0 ft Lc.k--.S c.l•4d •so-N
• 5st.Well Location: .. ._._ . ... . -- . -.. . . _. . .....-. 6.0 ft- -D it. - 1)(l eQ �•�i i r4Jl-G( ,-.
as:o.fL 3.ft._...-e -9. :/tom _lno J -
�Ja5ov1 �w�t��aet /�e fa��l. .. .-.- - - -- 9 •�1 /7�J V.e:�l
Facility/OnnerName Facility 1DI?(if applicable) 3 ft. ft- . 1; *n ✓ /ji. tT��'l �C�j !
/ _ U
/ II''A km-yaw
fr. ft:
f07A �"z?✓1 i t,Q_ rrel A'k fl YC1w A)c- 21 s 2-5 l .,.. I
Physical Address.-City.bnd Zip ft- ft. 4't • ; f Z�
l4-
Fret,irkkl t4 • Q 5 0 O(' / 21.REMARKS f
IOCT.a 9 2014 1
County Parcel Identification No.(PIN) ,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ih•;-I 1;.;?!
of well field,one lat/long is sufficient) - 22. u=; .,,t.^
.31o, bi f s 8 '' N 7 - ,2 t ,3 S v4 .- %�
6,Is(are)the well(s): VIPermanent or ❑Temporary ,gy;z0 A f-
• •Modof C ifeed Well Contractor Date``
• bo signing this Arm.I hereby certifi that the trellis)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15.1 NC.-IC 02C.0100 or 111 KC AC 02C.0200 ifell Construction Standards and that a copy
if this is a repair.Jill out known well construction information and explain the nature of the 4/this record has been provided to the well onrtar--
repair under#21 remar-l3 section or on the back of this fora*
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Youmay use the back of this page to provide additional well construction info
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.
Arucd 24.SUBA'iI9TAL INSTRUCTIONS
9.Total well depth below land surface: 60 0 (ft,)
For multiple wells list all depths 11d1fliment(example-3(0200'and 2(a)!00) Submit this GW-1 within 30 da)'s of well completion per the fallowing:
,� 240. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.
1(narer level is above casing.use"+' ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Idie (in.) 24b. For injection Wells:Copy Ito jDWR,Underground Injection Control(IUC)
Program, I636-MSC,Raleigh,N027699-1636 - ••
12.-�t'elhconstrucEion method: /Tl l� �Q .. ... __ .__ _
24c:For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,diret push,etc.) comity environmental health department of the county when:installed-- - .. --. -
FOR WATER SUPPLY WELLS ONLY: 1
_ _ •24d_-For Water Wells producing over 100;nnn DMZ.:Copy to D .CCPCUA
h, 4 .Permit Program. 1611 MSC.Raleigh,-NC 27699-1611 .
13a.Yield(gpm) I Method of test {cIl
•
13b.Disinfection type: y pOP.I l f 2, Amount: , 7.
1
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-201 S