GW1--06425_Well Construction - GW1_20241025

/ELL CONSTRUCTION RECORD(GW-1) For internal Use Only.
Well Contractor Information:
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b/w/tit e A, &Att._ lT(yA,t a d— A-G'^---,1 14.WATER-ZONES
11ContractorName FROM TO DESCRIPTION I
'374.-A- 39•2y-,4 . Z.6 r` , 63 it iaiiiiS 61.adre- /a
R.
4ellCo�actorCeltificationNamber 15.OUTER CASING told-cased wells)ORIMI RCda 1de)
�k GiJ�4�t-� Sol �s LG� M TO D» THICKNESS �, —
mpany Name
YJ 16.INNER CASING OR TUBING(geothermal dosed-loop)
Well Construction Permit it .5"/166 4J FROM TO DIAMETER THICKNESS MATERIAL
t all applicable well construction permits(Le. C,County,State.Variance,etc) / H- 571J ft- 4" . in. A6'10 AIL
.+
Well Use(check well use): f0 3 It !vim n T-I ' `J&d Pit
'ter Supply Well: 17.SCREENI
FROM TO DIAMETER SLOTSTZE THICKNESS MATERIAL
lgricultutal OMunicipal/Public 511 IL 4 3 IL i in. 1c S
isothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) iL it. ➢n.
ndustriallCommercial 212.esidential Water Supply uPP Y(shared) is.GROUT
rrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
n-Water Supply Well: G H. -,:2 / f. d IA.
ofonitoring ❑Recovery it it. �� d
ection Well: •
tt. it
,quiferRecharge OGmrmdwaterRemediation I
19.SAPID/GRAVEL PACK(if applieable)
tquifer Storage and Recovery • OSalinityBarrier - FROM TO MATERIAL I EMFL&CEMENTMEDIOD
,gtiiferTest OStormwaterDrainage cQ/ iL b.c $ -1/9Xep�n,j palm-
Experimental Technology ❑Subsidence Control i ! d" !
isothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
isothermal(Heating/Cooling Return) ❑Otter(explain rmdertl21 Remarks) FROM TO DESCRIPTION(color,mrdaen,wnrmcrctlnSgrata size,etc.)
Date Well(s)Completed: /t!i 9-•Zit Well ID/I c d IL 3 it GLfI'/y t y e t-,P q2.-
.Well Location: 63 iG lib IL dd' 4 644
r.bt -awe L� i?f/lc�/ IL ft. -_� __
is t ility/OwnerName Facility Dl(if applicable) !! >
32S /'yleg erg- LAI l t.fe-C "�i��. ft. 1tp
�siral Address,City,and Tap ?i73 fo B. iL OCT 2 •� LSZ$
vtL(Sn_�2 _ �oz>Qa 2L REMARKS fir`^ _ ux:a
mty Parcel Identification No.(PIN) j:c�,c '.%la
.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
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well field,one lat/long is sufficient) �, 22.a cation: r'��
� , z,o✓fl`'�3_el7�/ .
I S4)I / `t'Z 1 N '79 �3 1 t4 w f j 37L f} - // ' /4. -z.V
Is(are)the well(s): ermanent or • temporary- Sigaatme.ofCertificd Well Contractor Date-
Bysigning thisfonn,Thereby certify that thewell(s)was(were)constructed in accordencewith
Is this a repair to an existing well: ❑Yes or fro I5A NCAC 02C.0100 or15ANCAC 02C.0200 Well Construction Standards and that a copy
its is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.,
sir under#21 remarla section or on the backofthirform
23.Site diagram or additional well details;
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
istruction,onl 1 GW-1 is needed Indicate TOTALNUMBER of wells (add'See Over'in Remarks Box).Yon may also attach additional pages if necessary.
lied
� 24.SUBMITTAL INSTRUCTIONS
I
Fotal well depth belowland surface: /'6' (It)
•multiple wells list all depths ifdifferent(example_3( 200'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
( , 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: a
vier level is above casing use"4-- Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Borehole diameter: q ii rm,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Well construction method: ' "Z7i/J R04, 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
anger,rotary,cable,(Erect push.etc) county environmental health department of the county where installed-
iR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
i.Yield(gpm) lb Method of test: �' i•I
r.Disinfection type:Wea c4F-e Amount: 4''4‘a Q.
1.
m GW 1 North Carolina Department ofEnvuonmental Quality-Division of Water Resomca Revised 6-6-2018