GW1--06939_Well Construction - GW1_20241119

WILL CONSTRUCTION RECORD(GW-1) For Internal Use Only: a
1.Well Contractor InformaaJtion: .
Uli �e !� t!�h/G... if,„... 14:WATER'ZONES 3: f
, ,
Well ContradtorName FROM TO DESCRIPTION
2,c9.; o-9$, /Vr, rt.
/y ft. II
NC Well Contractor Certification Number '
/�/� / /I 15:: UTERCASING(fdr:multi-casedwells):ORLINER:(ifap'iicable)
� c;� • /��'/�C/�IS �i// !'i / lnC FRO� /f TO ' DIAMETER it G'/ rt.
//�; in. 1 Z�ds MATERIAL
_
CompanyName J j/ 6 1 v C
�j�` °16r>INNER'CASING:OR;TUBING(geothermaielosed400p) •`:.%
2.Well Construction Permit#: 2.- —2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable.well consultation permits(l.e.UIC,County,State.Variance.etc.) ft. ft. I; in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 97:SCREEN ;'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. ft. In..
OGeothermal(Heating/Cooling Supply) liliCesidential Water Supply(single) ft it. in. •
OIndustrial/Commercial ❑Residential Water Supply(shared)Y( ) r18:GROUT
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPCEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R' R' 4 G,,,9C Ak
❑Monitoring ORecovery ft. ft.
Injection Well:
fifer Rechargeft. ft.
OA qif • ❑Groundwater Remt:diation
OAquifer Storage and Recovery ❑Salmi Barrier -19.SAND/GRAVEL PAC&(if annlicable) ..` ;<__
tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test i ❑Stormwater Drainage n• ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal Loop) OTracer(Closed
°=20:°DRIILINGLUGTattach,additiotalsheetsifneces4ary) _ =: >-
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness wWrock type exam sir¢etc)
y►�, d rt. /0 ft. ', CA
4.Date Well(s)CompletedJi//- I t Well ID# IC) " 1'0 �'L, /%etk.
5a.Well Location: is .,zt 4,0 ft. / ft. /0,'/16 5/ 4'
(cc I-7 1 •/d6✓5 ';'151 f` Zj(bn' /i //�1
Facility/Owner Name Facility ID#(if applicable) ft. ft.
/0/3 //it ei^ dc/C� b )(4a.10 l•ot-3 ft. ft. t.!, c...'.s.» .,.,_,_-
Physical Address,City,and Zip • ft. ft. NOV
L R
r OPPay, `t ...
County Parcel Identification No.(PIN) lr.`;.....,.. '' • . - , ....
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field,one` lot/long is sufficient) �/ ✓J/�/ J/ 22.Certification: '
•
3 y S 9E7 V/ N ®C7'2/ /V 7 w /.‘,Zed..„,,g;V„,�
6.Is(are)the weli(s): rmanent or ❑Temporary Signature of Certified Well Contractor ate
By signing this farm,Ihereby certlfv that the well(s)was(were)constructed In accordance-with
7.Is this a repair to an existing well: ❑Yes or L91'la ISA NCAC 02C.0100 or ISA NCAC.02C.0200 Well Construction Standards and that a copy
If this ft 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 rentarlr 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,onlxl GW-1 is needed. Inndicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: (J 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2.00 (ft,) 1
Far multiple wells list all depths ijd(erent(example-3(0200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following;
10.Static water level below top of casing: (fL) 24a. For All Wells: Original j fort to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: £/' (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1 636 MSC,Raleigh,NC 27699-1636
12.Well coon method: /�-���`"� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger, tary,cable,direct push,eta) county environmental health department of the county where installed
f
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
i'!�13a.Yield(gpm) > �/✓
J
13b.Disinfection type: /!�� Amount: 3e sit