GW1--06885_Well Construction - GW1_20241118

WELL,CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information:
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c2 ce.C.: ilia iii/ /4"1 tag" dC..e- 14c'WATER ZONES.::::,.:-:':•:,;.:,ff:1;.:?,...:1:
Well Contractor Name FROM TO DESCRIPTION
Zl'>39 „ ft. //y ft
/s5 ft. /y.f)ft
NC Well Contractor CertificationNlmiber
15::OUTERCASING'forwuitl-wised wells ORLINER a Iteable
FROM ' TO DIAMETER THICKNESS MATERIAL
.49L /#44 AS ttitl i allin,
Company Name ¢q ft 0 ft ‘7� hi.
i ,1!d AJC-
`,� ,—D. 16 INNER:CASING:OR:TUBING,(geotherniahclosed=loop)
2.Well Construction Perlgit#: \v/ r FROM TO, DIAMETER THICKNESS MATERIAL
List all applicable well construction perinits(i.e.UIC.County.State,Variance,etc.) ft. ft. in.
4 3.Well Use(check well use): ft -ft in.
Water Supply Well: 37.SGREEN:,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) aseesidential Water Supply(single) ft ft. in. .
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft zO ft. Aferilieh)ilc it/
OMonitoring ❑Recovery ft ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 1.19:.SAND/GRAVECPAC&(ifapplleable): :
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ,❑Stormwater Drainage n• ft.
❑Experimental Technology ❑Subsidence Control ft. ft. •
OGeothermal(Closed Loop) ❑Tracer 20 DRILI ING LOG(attach additional•sheetalfitt essary)
OGeothermalFROM TO DESCRIPTION(color,hardness,sowUrocic type,Frain size.etc.)
(Heating/Cooling Return) ❑/Other(explain under#21 Remarks) 0 ft ft. ieed G/G+-x
4.Date Well(s)Completed: //-4'Z 1 Well ID# -3r) ft $0 ft S/€Ili) (,i
5a.WJllLocati� `�. p0 f. 15 ft. ,' /,etc- Sh f
/
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,C//ity,and Zip ('�(�
ot&C4-1/G(S Or, • l 1 1 3t 2I:RE14I ARK3:.:: i OVA':' 3h ,f ff l♦
County Parcel Identification No.(PIN)
Inlf,'.,,, .. ... ...,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
35, 5 72 9 3 N 'O. O 75/9. W ' I, �' Z '
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6.Is(are)the well(s): 1.41 rmanent or ❑Temporary gnattre of Certified Well ntmctor Date
/ Bvsigning thisJoret,I hereby certify that the wells)was(were)constructed in accordance.wlth
7.Is this-a repair to an existing well: ❑Yes or till‘ !SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 w11
ell 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Land surface: Z000 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd different(example-3(a)200'and 2®100')
1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: _,0 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6%S (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: C'- ( 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) U county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing aver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Permit Program,1611 MSC,Raleigh,NC 27699-1611
' CD Method of test: ,j,- •
13b.Disinfection type: /4 7/l Amount: 3,41,3