GW1--06908_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cf&Ffcev, 1 rc/fer /6.4.44,1 mac/fsorl `14:WATER'ZONES .:1-`
Well ContractorNttme f. FROM TO DESCRIPTION
4/6 o a 11 - ft., ft. r / 8SJ 6 0
ft. ft.
NCCM/Well Contrrctor Certification Number 15:.OUTERCASING(foriaolh-cusodwells)ORLINER(ifop litabte)'
K/t 4.• f Yl Lt_L//5 wet/ , i L/, _, 2w C FROM ft. TO ft DIAMETER in. THICKNESS MATERIAL -
Company Name v 1 ( �� o o�S (�G
/ 3 t 16•INNER:CASING:OR,TUBING(geotbermal'closed=loop)-
2.Well Constructioli Pernut#: / O to /-L' A 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well conshrtction permits(Le.UIC,County.State,Variance,etc.) R• B• in,
-
3.Well Use(check well use): R• R• in.
Water Supply Well: ;17 SCREEN .:.._ „_,.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. it. in.
❑lGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. In.
J�lndustrial/Commercial ❑Residential Water Supply(shared) .18r:GROiIT.
❑\Imgation ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft o?0 ft Zonjlepnik.,
Jo `
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft. f
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable) --
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20i DRILLING LOG(attach additional•sbeets ifnecessaiy) .
FROM TO DESCRIPTION(color,hardness,soitirock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft AO [t, e e C C /
4.Date Well(s)Completed://^s-oR1-1 Well BM a a ft I3 U ft• , Gee /Vr.own 5%��a-Cy SA:.Wel1 Location: -. /3 Oft 30 O ft /�..r�" � +rr n of /�eu e (gin.
UUc /
teY LL1,11�- f. ft
acility/ caner Name Facility ID#(if applicable) R• B• • > ; -
/l �f Cal A f H..-
A f`-y 21 hic.f r..g!/ieU€ coricp Rd. f. ft :,1,.,._-
P�iysical Address,City,and Zip �• y� ft.• ft. N O V j .:) j U L`i
d oat—O( n j-( 1 1 Z1:REMARiCS
/Ylt�c�( en bGtl' vVCC..` J /
County Parcel Identification No.(PIN) • I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3S, 1la3o/�s N 80. 1gr77/ W ll -5 -a�
6.Is(are)the well(s): 21 ••manent or ❑Temporary Si well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or I'.➢Nir ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
!fads 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 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: . 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _ .. 0 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths fdii different(example-3®200'and 2®100)
t 24a. For All Wells: Original form.to Division of Water Resources (DWR),
10.Static water level below top of casing: (1) Information Processing Unit,1617 i MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: D (fn.)
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: D 7
11 a r7 24c.For Water Supply and Open(Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depart finent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test /4 it , Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:J7(T/! Amount:,3 pi h f S .
i