GW1--06343_Well Construction - GW1_20241022

WP,LT,CONSTRUCTION RECORD(GW-1) - For Internal Use Only:
1.Well Contractor� IInformI'e Ss
atiion: .
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ON
WelConnector Name O'� 3 00 ft. r • ;".TO 1•
I coo um tyi
ft. ft. 1 `i .
tor
NCWell ul I U 4 d ��1 i� CO% D x;,... !31 ,r StiraA" MATRxw1� ,� � � FRt)M `` TOarN17E58rt THICKNESS A?A'l�t�CompagyName !� "� '" ' V
I J t'1 -1r .d:ie•sai . o' s`: r '=. i teal,.
2.Well Construction Permit#: L a Q .4 q 1 I 1 1 FROM To Du nETER MATERIAL
List all applicable well construction peiinfrs e.UIC,County,State,R etc) ft. it. I' In,
3.Well Use(cheek well use): ft. ft. In.
Water Supply wen: - - - a?17 ENK4": * .1 r rk• y, W'' r •.,Ia" •..c' C`*:4<
FROM
gAgtict►ltarat C]Municlpal/Pnblic }} TO ft, , DIAMETER' SLOTEIZE THICKNESS MATERIAL
•
OGeothetmal(Heating/Cooling Supply) Cifiesidential Water Supply
Olndusttial/Commerclal CResldential Water Supply(shared)
'51$o {P� �"�?totm�,• w-w �`<s`1� 0� %:ce
OlrsiQation OWells>100,000 GPD TO •
METHOD t&AMOUNT
Non-Water Supply Well: 0 it. 0 ft' beZ 1, imp:
°Monitoring DRecoveiy it. it. 1!g, d.
Injection Well: — 4
it. ft.
[IAquithrRecharge O(#rottndwaterRemediationplO it�E1 Or . •gip- "' %
OAqui&x Storage and Recovery OSalittity Baaier � M TOMATERIAL E
BILTHOD
°Aquifer Test DStormwater Drainage it. ft.
[]Experimental Technology °Subsidence Control it. ft. 1;
C iGeotbamai(Closed Loop) OTracer 'OW ` ' f • i` • e iity ark 3* .,r ,.; p
°Geot banal(Heating/Cooling Rerun) ClOther(explain under#21 Remarks FROM ?O DES T1oN Leaks tnNnetb�otvrcek tree.yam case,eto.1
•
0 ft' SO ft' r.b,i , l
4.Date Well(s)Completed: 15 ao--.:1"J Well ID# ..P? it 3 G 0 it. rrA h r` j (-0 c ,C
5a.Well Location: - ft. ft. j
-T - 111,il oehe5 IN ft. Nt R,E i� t_z.�
Faaiifty/OwnerNqn de FacilityIpk(if appl cable) ft. ft. n Crb D a e Craw) , roll �-.�(3U�1s17Gt1'p ft. n t eQ24
PhysicalAddteas, y,andZip ft. R. ; 11 37w4,-�::�; ?r(:•rev; 'Lie
r v t.T}
County Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: - i••
Of well field,one latllong is sufficient) 22.Certification: I' (N W -, 4JJ.4221A tJ~r °-aL
6.Is(are)the well(s): DPermanent or °Temporary 3i_., of Certified Wei Contractor r Date
Bystningthisfit."thereby cart*that theivall(s)was(were)constricted in accordance with
7.Is this a repair to an existing well: GYes or 116o ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard:and that a copy
Ifthis is a repafr.jill out blown well construction brjbnnation and explain the nature of the of fide record has been provided to the well owner.
repair under 4r21 remarks saciton or on the backofthisform. I•, '
23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info.
constmcti�only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over is Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INuSI'RUCTIONS
9.Total well depth below land surface: 3 5 0 i (ft)
For multiple welds list all depthsIfd/lThrent(example-30200'and WOO); Submit this GW-1 within 30 days of well completion per the following:
It) Strttle water level below top of easing: 2.4 I
(f.) 24a. For All Wells; Original font to Division of Water Resources (DWR),
Ifwaierl�ve!is above casing,use"+., Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
6v 6 I
11.Borehole diameter: 6114 (in.) 241:.For Injection Wells:Copy to;DWR,Underground Injection Control(TUC)
Program, MSC,Raleigh,NC 2 i 699-1636
12.Well construction method: a I f r0 � 24c.For Water Su a d en-Loo Geothermal Return Wells:
(i e.auger,story,cable,direct push,etc.) county envuomnen th ailment o countyw ere Copy to the
FOR WATER SUPPLY WELLS ONLY: P
(( 24d.For Water Wealsprodudng�e over 100,000 GPD:Copy to DWR,CCFCUA
13a.Yield(gpm) 1 '..rt Method of test: 1 Q 1I� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: h±n Amount: °- (, 1 b s