GW1--06966_Well Construction - GW1_20241119

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WELL CONSTRUCTION RECORD(GW-11 - For Internal Use Only: '
1.Well Contractor Information:
cfeFFr-ey 7'ccRey',./ 4 /InT c/1Son "'14WATERZONES 1 ., . : .:r . .-
Well Contractor Ni a FROM TO DESCRIPTION
10D pZ ./9 _ ft.; ft. 1-st', 5 ) OG 8
It. I J
NC Well Contractor Certification Number �15`.OUTERCASING:(for,multi-cased.wells)"OR•LINER(Ifap'llcable)
Vp� FROM TO ' DIAMETER THICKNESS MATERIAL
• ( j'i lid/i T (.XJie if V r 1/i rl Zit/c ^
-fr/ rt Lij rt &I/ in. t0eX_5 pvc,
Company Name 8
J I :16:INNER-CASING:OR TUBING;(geothermal'closed=loop)
2.Well Construction Permit#: • I`(!� FROM TO. DIAMETER THICKNESS MATERIAL
List all applicable well construction perm its i.e.UIC.County,State.Variance,etc.) ft. ft. I in.
3.Well Use(check well use): R' I in.
'17.SCREEN'::.; .;.
Water Supply Well: . .• ,�.,; . ..:. .:. .. : ,.., .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft. in.
❑Geothermal(Heating/Cooling Supply).., esidential Water Supply(single) ft ft In
❑lndustnal/Commercial,, , ' t ;,., ❑ esidential Water Supply(shared)
°irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Ol( 1 ital Li 0 ft . o it % e /
[Monitoring __�,•ERecovery ft. It • i p Sao[
Injection Wellif:`,:
ft.
❑Aquifer Recharge t..` -" ❑Groundwater Remediation
:19..SAND/GRAVEL PACK(if applicable): `
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test- ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. I.
°Geothermal(Closed Loop) OTracer •s20i DRILLINGLOG'(attach-odd itionalshee(safnecessary)
[]Geothermal(Heating/Cooling Return) ❑Othd r(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWrocktype,grain she,etc.)
/ j� 0 ft. a Oft i x 62d C� (ct,(.
4.Date Well(s)Completed: I "' 8 `"e2! ell ID# ° ,Oft 3 out ���,Oc c r i. ,So•,.r ,S —2.
5a.Well Location: 4 3 Oft f 3 hi 3'� roc- -z/if9lli.P s is ,
L-w3 Pk-Ali a- 0-- r.1 3 ft. 3 oe ' Vlte.P 6,«&'
Facility/Owner Name Facility ID#(if applicable) ft ft. I'
Lj$ 7 u s ca / wr it.tcYvci MG ft. ft
ft. ft.
Physical Addres,City,and Zip 1
1./w� \ -cs • 1 �� 21:RE14IARKS,?
County Parcel Identification No.(PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3G. 3 '7 °i6 6 N Ro. 9'7.515 w I/ _. $07y
6.Is(are)the well(s): rm eanent or ❑Temporary " Ce ' Well Contractor i Date
By signing this form,I hereby certtfv that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or leiNir 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repah:fill out known well construction information and explain the nature of the of this record has been provided to the Well owner.
, repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: O 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 o ( ) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ft-different(example-3Q200'and 2®100') I't
,�_/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: '7 a (ft) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
If water level is above casing,use
//"+" 1
11.Borehole diameter: P$ (in.) 24b.For Infection Wells:Copy tb DWR,Underground Injection Control(IUC)
nn 11 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Pl D 7-a r 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 department of the county where installed
FOR WATER SUPPLY WELLSONLY: 24d.For Water Wells producin,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Ft Method of test: f r Pit Program,1611 MSC,Raleigh,INC 27699-1611
13b.Disinfection type: hi T H Amount: 3 pi Y')-/-s •
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