GW1--06910_Well Construction - GW1_20241119

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:CAMA \
*pVCItt Gir c.-�Well Contractor Name FROM TO DESCRIPTION
Li3-32 ft., fr.
ft. ft.
NC Well Contractor Certification Numb
bL.
,un�/,\ r� ..15::Oi1TERCASING:(iotinul4-cased,itiells)OR LINER(if8p`lteable)' `�111 5 \ -- ,:it[ i FROM f� TO f� DIAMETER�. THICKNESS MATERIAL
Cop any Name . 1
�1 �� ;16 iiNNER'CASING:OR TUBING:(geothermalclosed=loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. -ft. i is
Water Supply Well: 17:•SCREEN '' ,.,.; _ __.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. .in.
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft, ft. in. •
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft. I "
Injection Well: it.
❑Aquifer Recharge ❑Groundwater Remediation
=19.SANDIGRAVEL-PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control it. it.
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❑Geothermal(Closed Loop) ❑Tracer 20 DRILLINGLOG ftittaelt additional theettlifnecessaiy). ' -
FROM TO DESCRIPTION(color,hardness,soirock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. f
4.Date Well(s)Completed: {'7' 02-4 Well ID# ft. ft. "
5a.Well Location: :it ft. ft.
ck �. nca1S Cszit LLCM f. ft. NOV 1 :i iU14
Facility/0 rName Facility 1D#(if applicable) n' R•
t\' E. ncsi, b1.c ft. ft. D':V- . ; ::3
Physical Address,City,and Zip ft.• ft.
lAerA KC1( a , cc) O 1 a4 23REMARKS: ,r •r "
County Parcel Identification No.(PIN) �4e Se
0•( &S Atli. / � I8 VI. $l.441 t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `K v+L l"date
(if well field,one let/long is sufficient)
22.C rtifi 'on:
N W
6.Is(are)the well(s): Permanent or ❑Temporary E; o Rifled Well Con or Date
+" By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Yes or ONo ISA NCAC 02C.0100 or 15A 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 remark section or on the back of this form. 23.5ite 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3®200'and 2®100')
I 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 Method of test:
13b.Disinfection type: I� 1 1+ Amount: k •