GW1--06956_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
�erf,e�� /�' r /G-
`7/ I�GG ti' CLU in TAX G ITS O Y1 1.,kMATER ZONES :.:1 l -' ' _ . ..
WeliContractorltame FROM TO DESCRIPTION
. ft ft., . i I� 4 p .1.Q 10 oZ.L/5
t 7
g 6 0 A ft. ft. I
NC Well Conunctor Certification Number `:15 OUTERCASING:(for_multicased'ivellsy:ORLINER(SEap' Iltable)
. G• c(.!/�s �Q 6l Gp/s;`!;!1�y ��t^ FROM TO ' DIAMETER/ ft Li 3 ft. %8 in. THICKNESS
ca SSS MATERIAL
Company Name p Q ::16rINNER:CASING:OR:TUBING(getithermalclosed=loop) . P
2.Well Construction Permit#: O r� I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC.County.State,Variance,etc.) ft. ft in.
6 3.Well Use+(check well use): ft -It. in.
17.SCREEN ;_ • ,.
Water Supply Well: ,:_ . ..: .,:< .,. . . .., . :. -_.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural O��Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) tBResidential Water Supply(single) ft ft. in. -
Dindustrial/Commercial OResidential Water Supply(shared)
.18i GROUT :. .,
❑Irrigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft of�l O (t r749 "____ __ /
❑Monitoring ORecovery ft. f. ��"�`
Injection Well:
ft. ft. ,
OAquifer Recharge OGroundwater Remediation ",19:SAND/GRAVEL'PACIC(ifapplicable)' `:. ..
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test, ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
0 Geothermal(Closed Loop) OTracer 20DRILLING-LOG(attach>idd►tlorialsheetsifne"cessary) . :
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(rotor.hardness solurocls type grain she.etc.)
0 ft. S ft e C.lvy
4.Date Well(s)Completed: 0{' ! t� /Wel1 ID# ft. L/3 ft q3/6�„Q 6. /.
5a.Well Location: n ;E , ' , t\ 4/3 ft. 3 O 2 c.. 4, G.n•.-Le.
3 u3h` t,Uri Son ,c i— ft. ft -x;
[t ft.
J Facility/Owner Name Facility Tl�(if applicable)
D 35 Ste-epy NlD!!,Lc/ Rd f` Nov i 6 LG24
Physical Address,City,and Zip / ft.. ft. - .`✓:.,c:-;f J rti:
C cc.b a rr t(_5 21t'REMARK$r' y,it i t ' 1 i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
'''`:- = 35 , a3 3_3 g N 30• S5.(s I-1 W 1.64eio , q-a.i,
6.Is(are)the well(s): 21 manent or OTemporary Si ' Well Contractor Date
/ By signing thisform,l hereby certify that the well(s)was(were)constructed In accordance.with
7.Is this-a repair to an existing well: ❑Yes or Sri ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to the well owner.
I repair under#21 renmrls 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 G�-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: 3 o 0 (ft.) Submit this GW-1 within 30 days,of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2®100')
I L' 24a. For All Wells: Original (form to Division of Water Resources (DWR),
10.Static water level below top of casing: `7 v (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" / 1
L.
11.Borehole diameter: V/g (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
/(i
12.Well construction method: / D /4/"y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depiartment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciu2over 100,000 GPD:Copy to DWR,CCPCUA
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13a.Yield(gpm) Method of test:
i Permit Program,1611 MSC,Ralleigh,NC 27699-1611
C�J
13b.Disinfection type: !7 /hi Amount: i/L-fs