GW1--06925_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well\\ Contractor Information:ZrCb
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Well Contractor Naiad FROM TO DESCRIPTION
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NC Well Contractor Certification Number 1
.15:OUTERCASING(formulti-cased wells).OR LINER`Oran`Ilcable)•'.: ; "::.-: :,:
M DIAMETER
AE R THICKNESS MATERIAL
L. M..\\;5 .,..�� Ze \\ Ng .�U � ;� ftySft' L in, . .5Company Name
.����^ ., :16•INNER:'CASING:OR T[IBINGi(geottiermalclosed=loop) ..
2.Well Construction'Permit if: !� d FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constru tion perittits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
4 '
3.Well Use(check well use): ft. •ft. tn.
Water Supply Well. 17sCREEN .:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. It. 'in.
❑Geothermal(Heating/Cooling Supply) ldential Water Supply(single) ft. ft: in. •
❑lndustrial/Commercial DResidential Water Supply(shared)
❑Irrigation DWells>100,000 GPD • FROM TO MATERIAL EMPLACEMENTME OD&AMOUNT
Non-Water Supply Well: a It* a-o It,- 64{1i `► C'Q
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DMonitoring DRecovery ft. ft. T+�
Injection Well: ft )Q
❑Aquifer Recharge • OGroundwater Remediation
.19:SAND/GRAVELPACK(ifappt :able) ..._ -°
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft '
OGeothermal(Closed Loop) ❑Tracer • -:20:DRILLING LOG(attach:additionalsheets ifnecessary) . .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TOt DESCRIPTION(color.hardness,soiliry tyre wain sire etc.) ~
/- '](� O ft' L O ft: b VOLO 1 J
4.Date Well(s)CompletedP14to ►-l Wen ID# l0 ft. .(')® ft: t` 51%ci S.L ,
`Saa..WellLocation: t.r i SOO ft. �r Si�4c .
Facility/Owner Name Facility iD#(if applicable) ` ft. ft. y 4.,, .: •; . :1,,,,,
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z.ct) %t.Ant �.,.� , - tx\cz.v...Nx.. tG Nov 19 2021
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.�C e M.a�r es, `1`E \Lk( "SV S�y l 0 21:;REMARKS: .... :- ., • t
County Parcel Identification No.(PIN) D.: "` '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce • ation:
N W ai,17GG,tx LI
6.Is(are)the well(s): 13Peanent or ❑Temporary Si of rtified Well Contractor Date
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By signing this orm,I hereby certify that the wells)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or 11ii'Lo 1SA NCAC 02 .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 thls 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 500
(ft) Submit this GW-1 within 30 per dti s of well completionthe following:
For multiple wells list all depths if different(example-3@200'and 2®100') y p
I 24a. For All Wells: Original;form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,I617 MSC,Raleigh,NC 27699-1617
If water level!s above casing,use•'+"
11.Borehole diameter: NI5 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-I636
12.Well�i�action method: �O ere-� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger tL'L'lt� .ble,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY vvv1.1-,S ONLY: 24d.For Water Wells producing,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) !V- Method of test: A;'Y' Permit Program,1611 MSC,Raleigh,NC 27699-1611 ,
13b.Disinfection type: -► Os Amount: p%ni