GW1--06955_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
,1�e.FFr --ru.c./1 e r /CV in al r:/'j 1) 14`WATER ZONES :.
Well Contractor Natal FROM TO DESCRIPTION
Li& oa... _ ft. f 1 L�o, a/o
NC Well Contractor Certification Number .15:'.OUTERCASING(for multi-eased.welis)'OR LINER(if ap Itcabley.,•::r:::
tJ �. ����L..S well
// ��/ .!1 Q FROM TO DIAMETER THICKNESS MAATTERIAL
• Company Name l[ i/,l/' 2y C- ..i..1 ft t / ft e' in. a. / vc
.:16 INNER CASING:ORTUBING(genthermelclosedaoop) •:'. ..
FROM TO DIAMIi1ER THICIINFSS MATERIAL 2.Well Construction'Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft •ft. i in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural ❑M�unicipal/Public ft ' it. Lin.
❑Geothermal(Heating/Cooling Supply) #Residential Water Supply(single) ft. ft in.
❑lndustrial/Conunercial [Residential Water Supply(shared) 18c GROUT:
❑Irrigation ❑Wells>100,000GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. oZ D ft. WV E/rz o—r[a /
OMonitoring ❑Recovery ft f. a ��Rol
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK(if applicable) •.' _-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage R• ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer • '10 DRILLINGLOG(attach:addidonalsbeett.ifnecessrfry)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(ro/tor,hardness soIDmck type grain stze eta)
tD ft. a 0 ft. tl n`.ee C L
4.Date Well(s)Completed: /0"S-ail Well ID# d o it. 9/ ft 1-P.-e4'` G
�;q / /� D ? j a,
( 5a.Well Location: ail-
;; % ! f' W O R' P-e; '6„t�,,.�.1 Lets.€ (,t.esyt.1L��
5osr e"- 1A lltd t• ti)W15+ Wed!! ft. ft.
Facility/Owner Name / / Facility ID#(if applicable) /� ft R. _
3/Jw old SC.c,.C.ishur ,- ioi.ccrd i2d f. ft k_ u a'!:4
Physical Address,City,and Zip . ft ft.
A
Cu.b a.r f Lt.S ` • 21:REMARKS: ..- (JtJ•V 4 O: ?-4
County Parcel Identification No.(PIN) :- ,1,o'-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 " ` -`"•'
(if well field,one lat/lloong is sufficient) 22.Certification:
•35 '1S Q N go. 5'1S 8�- W lieeALt
_� ofGeftified Welt C ctor — 0 5`a D/
6.Is(are)the well(s): 17Yermanent or ❑Temporary
�/ By signing this form,I hereby certt&that the wells)was(were)constructed in accordance.with
7.Is this a repair to an existing well: Cl or LRigo 1SA NCAC 02C.0100 or 1SA 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#2I 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: D '24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: il 0 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(((different(example-3Q200'and 2®100')
t 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: el 0 (ft)
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)
n 11 Program,1636 MSC,Raleigh,NC 27699-1636
1'12.Well construction method: ©7�r x 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
13a.Yield(gpm) Method of test: J /^ / Permit Program,1611 MSC,Raleigh,NC 27699-1611 .
13b.Disinfection type: 4 7-II Amount: �J p 11_T' S
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