GW1--06909_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
- `reFFre, T` fly r /6.et 1J/i
h JctG�'pn �14:WATER ZONES �. ;.1-_:
Well ContradtorN a FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number - '
15 OUTER CASING(for multi-cased;wells)`OR LINER(If up"Iicable)=:':; `:-
9),L. to�/// c U A/e // Vf./r///n :�e FROM TO DIAMETER THICKNESS QJ MATERIAL
Company Name J W 6 i✓ L l _ / (f, /0 3ti ( 1/S in. *as
I Q vC
/(� G� 16;IINNERCASING:OR:TUBING(geotherinajclosed+l000p)� /
2.Well Construction Permit#: /e2 0 / L 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.CIIC,County,Stale,Variance,etc.) ft. ft. in.
., 3.Well Use(check well use): fu fr. in.
- Water Supply Well: IZ:SCREEN :.`
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. ft. 'in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) g, ft. ,In.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irri anon -
$ ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C ft. a 0 R. /�,�
(tG 4,7Aon i ie po ct r L d
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A rfer RechargeD !
qu g OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salmi Barrier '19.SAND/GRAVEL PACK`(if applicable) :. _
tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test i ❑Stor mwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer "20 DRILLING LOG(attachadditiorial sheets If necessary): . ..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness solVrork type panlm size ete.)
D ft. J 0 ft: i d G
4.Date Well(s)Completed: /0-a3— Alikell ID# 2 D It. go ft. P./%L4 6�/l
Well Location: :" q) ft. /0 ,m; G r _ _ „/��L9Le p G �
( ` SS /0 3' 3 DOL :l & G.•r.,,,
acility/Owner Name Facility ID#(if applicable) ft. ft. i
1y13, "rile mPson Rd. ft.
Physical Address,City,and Zip ft. ft.
I� ��5-U1�` ��
21`RElYIARK5_-
tt?G/ Len bar I
County Parcel Identification No.(PIN) N O V 1 i' 2021
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certifi a Ir':` """' ` ', _ '
"
rc Hon: �.y
LDS. 1.3 731 N So'. LL43 2 _ W
6.Is(are)the well(s): ermanent or OTemporary
di g ed Well Contractor) Dare
�' By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &li ISA NCAC 02C.0100 or 1SA 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 oldie of this record has been provided to the well owner.
repair under#21 remark'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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: f) 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: DD I
For multiple wells list all depths if different(example-3( 200'and 2(a31009 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
((water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: �� (/$' (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(WC)
Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: go 7v/'1/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
e 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) .) Method of test: gj/r r Permit Program,1611 MSC,Raleigh,NC 27699-1611
•
13b.Disinfection type:./7-/iJJ Amount: 3 p,t y)-kf