GW1--06552_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
3�Of 0
14=WATtitzoNES T
FROM TO I DESCRIPTION
Well Contractor Name ft. J�f ft. ^/�
2�ig 0 LI.ps I ,7 1
ft ft.
NC Well Contractor Certification Number ;1S:OUTER CASING'(foi?iiialti ensid�vells)ORLINER(ifen livable) _ _ _
FROM TO i DIAMETER THICKNESS MATERIAL
���� AILf 1 l YI KJf� lA)Yil.t �PV 7 i/(V�f�� in. 1 .
ft. P� ft. t.. j NC
Company Name `� 1�C 11
NFL,
",i1-., ,.16,lNISTER:CASINGOINTUB NGln-eothertrialelosed:loup)
2.Well Construction Permit#: U Y (.V�`1—�V 1�� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
17 SCREEN. ;g . + ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*iAgricultural DMunicipal/Public ft. ft. ; in.
*!Geothermal(Heating/Cooling Supply) MI residential Water Supply(single) ft. e. ft. in.
*i Industrial/Commercial DResidential Water Supply(shared)
1 Irrigation FROM TO MATERIAL tEMPLACEMENT METHOD-&.AMOUNT
Non-Water Supply Well: /1 ft. �ft. r� � j 1n i ` "." ` 4 t
it Monitoring DRecovery Fl° ft. ft. l ttc/L Nov
a 1 ',,;n d
Injection Well:
*Aquifer Recharge 0 Groundwater Remediation ft. ft. In
.19'SAND/GRAVEL PACIt(if applicable) • .. ,.e z '-' [.is f
*Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
%AAquifer Test DStonnwater Drainage ft. ft.'
*Experimental Technology 0Subsidence Control ft. ft.'i
*Geothermal(Closed Loop) OTracer :2tIDRiLLWGIOC(attich:addi6onal•sheeta`ifnecess"azy) f . ,
FROM TO DESCRIPTION(color,hardness,soiltraek type,grain size,etc.)
111 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 5D ft. CA
4.Date Well(s)Completed: I2-t IN
1 Well ID# :)-D ft. /7 ft. �
ft. ft.
$a.Well Location: I ,
ft. ft.! '
Facility/Owner Name Facility ID#(if applicable) ft. ft.
] �Q ../_ ��f / G ft. ft.
111 lR i ri :l!`, ;'ti:J rdl-tr Dri1 ` ft. ft.
Physical Address,City,and Zip
12)1,,,t0rdttil M 3111-gcoiS
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: J�
35.941 N „r� .722, W i 9itit , 12,3
6.Is(are)the well(s MI Permanent or ['Temporary si nature of Certified Well Contractor Date
By signing this form,I hereby certify,that the well(s)was(were)constructed in accordan
7.Is this a repair to an existing well: DYes or tallo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and thm
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or wi
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I l_t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of wi
For multiple wells list all depths ifdierent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: l.�An,
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l✓ tigt+ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 21
i 711 rL��'®� I above, also submit one,copy of this form within 30 days of completion of we
12.Well construction method: 111 construction to the following:•
((i.e.auger,rotary,cable,direct push,etc.) (
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: 7.11(111 24c.For Water Supply&Injection Wells: In addition to sending the form
�' � the address(es) above,Ialso submit one copy of this form within 30 days 1
13b.Disinfection type: ktili Amount: . completion of well construction to the county health department of the coun
where constructed.
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