GW1--06953_Well Construction - GW1_20241118

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
+reFFrez 1kc/fer/64.t../y1 �at-Gr/rj0h 14 WATER ZONES .
Well Contradtor N e FROM TO DESCRIPTION
(o O CI— ft. rt. ill D a 1/3.ft. ft. 1 J
NC Well Contractor Certification Number
y/�1r�� /y� a -15:OUTER CASING'(foi malt iised.Wells)'OR LINER-(If ap liable) '"
• IC./s L, /t'ICG`/f i t let f DTI I t/ Il��i. 2y e, FROM TO DIAMETER THICKNESS MATERIAL
l 1/ ft.
ft in. av C
• Company Name
/' 3 v /
2.Well Construction Pertl3it#:
Z DA '16 INNERtCASING OR:TUBING:(geother nal'dosed=loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count, tate,Variance,etc.) ft. ft. in.
< 3.Well Use(check well use): ft R. in.
4 Water Supply Well: ?17sCREEN:.;; `..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
OGeothermal(Heating/Cooling Supply) fill sidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑I rigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. (2,0 ft ve/I-Fo i
/1 >c,.. p,ured
❑Monitoring ❑Recovery R, ft.
Injection Well: o
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
uifer Storage and Recovery '19.SAND/GRAVEL PACK(if applicable):
❑A
q ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test i ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20rDRILLING LOG(attach additionalsheets Ifnecessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION Won 6mdness soi/rock type grain sire.etc)
4.Date Well(s)Completed:it, a.-c2 "I Well ID# fa,0 ft. 1.713 D. 6.A...e G r.„3:t.zcz,
5a.Well Location: ..,i 1.4'3 ft. 3 0t4 I( 6 •
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ft. ft.�n�� ' Ley_......3,z;47-
Facility/Owner Name t Facility ID#(if applicable)
3 (oy(D t cyder Rd 'T y
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Physical Address,City,and Zip ft ft. N O V I S C U 14
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ccf.hetfra S 21 REMARIGS
County Parcel Identification No.(PIN) 1r J . . .
�;ti;' ". .51i;L,'atitude and longitude in degrees/minutes/seconds or decimal degrees:
•.�(ifwell field,one lat/long is sufficient) 22.Certification:
3 54 LH 3 1/ 3 N g o. 31112R3 . . W
6.Is(are)the well(s): i nent or ❑Temporary Si C ed Well Contractor,
i 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 al o ISA NCAC 02C.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 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: 0
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: e Q I'
For multiple wells list all depths ijd�erent(example- 200'and 2®100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Ai Q ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use '+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: & //U (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
(� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1�.©i-4 T t/ 24c.For Water Supply and Ojt In-Loop Geothermal Return Wells:Copy to the
(ie.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
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) a o Method of test: /
13b.Disinfection type: t / `,1 Amount: 3 e;v) I S ,