GW1-2022-07186_Well Construction - GW1_20220729

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For internal Use Only:
WELL CONSTRUCTION RECORD(GW-1)
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1. e11 Contractor Information: 4;
FROM O ESCRIPTION
Well�ctor ame +( ft. ft. �I
a's3 4 A ft. T,7,aft.[ I-Kr, 4,
NC Weil Contractor Certification
J� Num
� ,,� :<rolJl'E�]C7.1S�N, ('gi'ttful, .s,:�tEi¢•tiNulls�=�R:L^1N.�i2iPf2aPP!Fatl� =� y
-11t_ -,,,-t-t ad i I I).D I t,�t na ROM O IAMETER HICKNESS T IAL
Company Name ft f, a 5- in
2.Well Construction Permit# ©o�o� a7d�( OS� .. ERASING`D `fUBINSs: ltte:.;:>i1, to3ZidtCili)=z z� T � _, Y
Llstaeappecabfe weRcont-Won pennft(Le.WC.Count;State,Haftm,eta) ROM O IAMETER HI 5S TERIAL
ft ft In -
3. Well Use(check well use): ft ft In
Water Supply Well: 7�5, ,F�EE�?�n•z.cy; ��s�'; ��`'r-Y'� -:?„�'';:;:' :.t�;;:i'�,:<• ?•:.:...:s_.�:�£�-k'.'�"
❑Agricultural ❑MuncipailPuhGc
ROM frO ETER LOT SIZE �ICKNESS MATERIAL
❑Geothermal(Heatlng/Cooling Supply) Q'lesidential Water Supply(Single) ft ft in
mm ft ft In
Industrtal/Coercial ❑ Residentlai Water Supply(Shared)
❑Irrigation •, ri .'.r x
:'Rtv Rr-:YS
ROM TO IAL EMPLAGMEkIT METHOD&AMOUNT
Non-Water supply Well: ft ft
❑Monitoring ❑ Recovery U ft .47 e, u r
Injection Well: ft ft
❑Aquifer Recharge Groundwater Remediatlon OM O ERIAL MPLACEMENT
METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft
❑Aquifer Test ❑Stormwater Drainage (t ft
❑Experimental Technology ❑Subsidence ControlL- G
(Closed _ :<.0a f? ldtltt[ts(i�StB ._ Yii } �
( P) ❑Tracer ROM T O ESCRIPT
❑Geothermal ION color,hardness,soll/rock
eothermal(Heating/Cooling Return) Other(explain under#21 remarks) ft fit
( type,grain,size,etc.)
❑C
4.Date Well Completed: Well ID# ft ft
So.Well location: ft ft n t
WiWckm Tasllor sft ao5ft
Facilty/Owner Name Facility ID#(if applicable) Itil ft
02 75:�' Pn�.A h ftl ft
�iysical Address,City and Zip ft ft
raiq�l ?h 2 7 04-}34 35�(o Ks, ,-� t - ,�.
.���_. ,::�: ,:L... '� .�.., .ems=
County Parcel identification#(PIN) S n ed
5b.Latitude and Longitude in degrees)minutes)seconds or decimal 22. ERT t AT ON:
degrees:
_ 6 l-�>
N W _SRgnatuPbW Certified Well Contractor Date
BY d9nNg ft tam,t herebycenft that the we8(s)was(ware)constructed in acco dance with 15 A NCAC
6. Is(are)the well(s): UrPennanent or ❑Temporary o2C.or0oorf5ANCaCo2C.ozaowexconswcmonstandardsaWffiatecWofthisnecmchasbeen
— p tided to the we#owner:
7. Is this a repair to an existing well: INKS or ❑No 23.Site diagram or additional well details:
fl this Is a repair,lilt out!Drown weft construction Informflon and explain ft nature of You may use the back of this page to provide additional well site details or well
the repair under 421 remarks secdon oron the back of this form, abandonment details.You may also attach additional pages If necessary.
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the SUBMITTAL INSTRUCTIONS
same construction,only 1 GW-1 Is needed. Indicate TOTAL NUMBER of
wells drilled: 24a.For All We Submit this form within 30 days of completion of well construction to
_ the following:
9.Total well depth below land surface: (ft.) Division of Water Resources,Information Processing Unit.1617
For multiple wells fist a!1 depths IFditrent(example-3 200'and 2(Qa 1007 Mail Service Center,Raleigh,NC 276994617
10.Static water level below top of casing: 4_(it.) 24b,For Injection Wells:In addition to sending the form to the address in 24a above,
ff water level is above casing use+" also submit one copy of this form within 30;days of completion of well construction to the
11. Borehole diameter: - (2 (in.) following
12,Well construction method: - r o�GLt'l� Division of Water Resources,Underground injection Control
(i.e.auger,rotary,cable,direct push,etc.) Program,1636 MailService Center,Raleigh,NC 27699.1636
24c.For Water Supply&Injection Wells:In addition to sending the form to the
FOR WATER SUPPLY VVELLS J 1 ONLY address(es)above,also submit one copy of this form within 30 days of completion of well
13a.Yield(gpm): Method of Test construction to the county health department if the county where crostructad.
13b.Disinfection Type: � mount u 2_ '
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 PAGE 2