GW1--06555_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
r
I
\-1�rK i S7.V'l 112—r ^\ is WATER ZOlvEs. - .::
Well Contractor Name FROM TO DESCRIPTION
b n• 3 It ft. �d llo..,,
693� Pi- ft. ft.
NC Well Contractor Certification Number
fI�J `n 1�^ A.S:OUTER CASING-(for mull lensed weRs);OR'LINER(if ap&able,- -
I D �p Q vats /r FROM TO DIAMETER THICKNESS MATERIAL
Company Name
:.16.INNERCASING OR TUBING:(geethenitulClosed-loopy. :, '
2.Well Construction Permit#: !l td ti"" 60 L' 4 0 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC,County,State,Variance,etc.) O ft. 3'7" ft. • zrtn, •m z i fv
3.Well Use(check well use): ft tt fa
Water Supply Well: 17 SCREEN' _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it, it. !in.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)pp yh
( ) 18E-GROUT
igation FROM TO MATERIAL EhIP "
❑Irr CEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft 2,o ft. 4Lfph t
❑Monitoring - - - ❑RecoverY ft. ft. t /blt
Injection Well: ��r
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
79 SAND/GRAVEL PACK'fifaPplicable).,; _..,_:;, :.-r �.__'-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage B• ft
DExperimental Technology ❑Subsidence Control ft. ft. ,
❑Geothermal(Closed Loop) ❑Tracer •21/DRILLING LOG(attach additional sheers ifriecessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) '
6 ft' 32_ ft- (G 1 if.x yhivetr i kra.eivN
4.Date Well(s)Completed: /D — Ili- 2y Well ID# 32 it 3ZS ft- `ra rt
5a.Well Location: it: ft. _
5 Kot:Jc place, L LG ft. ft. ;. 't-.:'ft; ,,'.. %,.
Facility/Owner Name Facility ID#(if applicable) ft. ft. NI(J 1! n A
ar e 4,vc ,w sf.. •�=}she Co, Pc. 1696I ft. 1 'F
Physical Address,City,and Zip ft. ft lC'`:� rr."> cn,, %'�,.n. .,• vs...
LArCared20_ °I 61184splo1066o6 21:ERFM'ARKC ..,_ :_ ._ TMsf? ,� t,-Y2»
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:
3S. St143 N ez- sS233 wIPIPir
/ —.— —�� 16 • I G -zy
_- _ 6.Is(are)the well(s): Ca1P'ermanent- or__-DTemporary Signature of Certified W-I Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or two with ISANCAC 02C.0100 or I SANCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill out known well construction information and explain the nature ofthe 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction detail¢. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 2s' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifd different(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: 6'o (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. (D' 2 r (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
04-ck,k , above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: la,. COhirlineee. 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
t 13b.Disinfection type:C.41 IOeIr't Amount: 3 1-G. ,3 completion of well construction to the county health department of the county
where constructed.