GW1--06951_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: l; '
7a1,Well Contractor Informa�ti�on::... ��,24.4t- _.... ...„,ee,. ....t.......q
ir,„..., 14zWATER ZONES ::: !.:-I ",
Well Contractor Name `" TO DESCRIPTION
A /FOI I I
03 ft:' ft.
NC Well Contra or Certification
caatioonn Number +� O�
f /%/!'��'�K/ �l/fJ ' f;RGSIN (f ROR Ifp1Ubl)O DIETR lf3 61% ,v(5' f°Vc
Company Name /' �1 We:"
,✓ ] J J 16.INNER.CASING:OR;TUBING,(geothemial closed:loop)
2.Well Construction Permit#: (.,4 - we— W2J7 OO//( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable Well cgnstr#ction permits(i.e.(I1C County,State,Variance,etc.) ft ft II in.
3.Well Use(check well use): ft ft. I in-
4 Water Supply Well: FROM�E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -
❑irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL t I EMPLAACEMENT Mer1[iOD&AMOUNT
Non-Water Supply Well: C ft. 1 it !0 'N 4O fO I/(4,
�f©i r'C.A,
❑Monitoring ❑Recovery ft. ft. I
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation `19.SAND/GRAVEL PACK(ifmppUcable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. 1
❑Experimental Technology ❑Subsidence Control ft. ft. ;"
❑Geothermal(Closed Loop) OTracer ::20.-DRILUNG LOG(a thch-Iddidóha1sheein if necessary) :.5 -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) . FROM TO DESCRIPTION(color,hardness soil/rack type,gram sne err.)
ft ft !Clq
If
4.Date Well(s)Completed: I I L3 2 y Well ID# ]0 iZ 1 ft 61,9 f1 S I ci,i e
5a •
a.�.Well Location: tli �y )) (gyp /��/ 05 ft. zt 3 ft. i_(tom 5���,�
/U✓C5'7�dy1 � Z dc-6. �!a 1i0Cdtij 1 ft / ft.
'C1 / ( t 1
,3 ao4
Facility/Owner Name FacillID#(ifapplicable) ft ft,
/0/ 0 /149,e. � 4 ft ft ._a'C..;
a
Physical Address,City,and Zfp J ft. ft• ` "'(":-'P.. n a , '.:
( ezi'dte S 21 RE1GIARKS N O V 1. a: LG 24 ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I r,`'"
(if well fiiee//eld,oneellet/long is sufficient) 22.Certification: I,
N
5c,e-/..0. w 76,e,,,,,,,e}go, &___ .
6.Is(are)the well(s): manent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance.tvlth
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,JFH out known well construction information and explain the nature of the of this record has been provided to die well owner.
repair under#21 renrar•l''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 1QW-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
/ I.
9.Total well depth below land surface: ©© (ft') Submit this GW-1 within 30 days of well completion per the following;
For multiple wells list all depths ifdidferent(example-3(0,200'and 2®100')
/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 30 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
r
_jS i (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �Y a Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4 I Y R.O tq RJ 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) . b Method of test: /4/1
i
13b.Disinfection type: /T Tn Amount: I VI
1