GW1-2022-09282_Well Construction - GW1_20221006

WELL CONSTRVCTM RECORD(GA-1) For Internal Use Only:
I.Well Contractor Information:
(,!it tr re,+ r5:�� 7 3 EM_ems:n 3
FROM I TO DESCRIPTION
Well Contractor Name ft. ft.
'-I 5 ys-A ff. tL
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Cawt1IS V--e- l a NL I Pf/WL10 p ft. -7 o ft. C. in. S'oA 2.t VVC,
Company Na a d1 . e`Atlie i ;_
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): n• ft. to
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public tt. ft.
Geothermal(Heating/Cooling Supply) E§Residential Water Supply(single) ft. tL In.
IndustrialtCommeroial [Residential Water Supply(shared)
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q tt. 2,0 tt. L(
Monitoring 13Recovery ft. ft.
IF
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Remediation z�. �,La
.� �� z- : •r•.
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [Stormwater Drainage ft. ft.
Experimental Technology ,� [Subsidence Control
Geothermal(Closed Loop) [Tracer 'Y 'r+D Gt ' . a"pC �b n b"t6•ti -
Geothermal(Heating/CoolingReturn) (explain under#21 Remarks;Other FROM To DESCRIPTION color,bardaeu solUrock rain si ate.
rt. rt. A
4.Date Well(s)Completed:091o2•1z'- WeIIID# '71 ft. z it• 6Vct•1
Sa.Well Location: ft. ft. - -
ft. ft. S-
�t.n t wt l�.�r✓{.v� 80 be - OCT,r
�Faacilityy//Owner Name 9q�� ��• I_ Facility ID#(ifappiicable) ft. ft. O C�
_`I S V olt m 1 4-• (/r- /V fit)0 2022
n. ft'
Physical Address,City,and Zip n• ff. t ""
' :'2'ls• h1' yes � '�:/tor a.:��, -xS-.tr ��AZ �2 p�ra7 �Y„ „ Y'2?a.'.:.
,Mc rlt,tre l
County Parcel Identification No.(PIN)
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
(ifwell field,one lat/iong is sufficient) 22.Certification:
95,55g17 N -81 .gOTzW w 9 Vic)
6.Is(are)the weil(s)OPermanent or [Temporary
Signaturo of Certified ell Cont for Date
By signing this form,!hereby cent jy that the rvei!(s)was(were)constructed In accordance
7.Is this a repair to an existing well: [Yes or rWo with 15A NCAC 02C,0100 or 1 SA NCAC 02C.0200 Well Cowlructlon Standards and that a
{'this is a repair,'lll out known well construction Wormation and explain the nature of the copy ojthis record has been provided to the well owner.
Yepalr under 021 remarks sectlan or on the back ojthis jorm. 23.Site diagram or additional well details:-
You may use the back of this page to provide additional well site details or well
8.For Ceoprobe/DPT or Closed-Loop Geothermal Walla having the some
construction details. You may also attach additional pages If necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of walls
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2-6 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths('doerent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing? 19 0 (ft.) Division of Water Resources,Information Processing Unit,
(f waler level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In'addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method-. 4-,-,✓1/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Irjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 2709.1636
j
13a.Yield(gpm) Method of test: A ti Y'_ 24c.For Water Snugly&Inection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Dislnfection �d`,�t2C Amount: -S completion of well construction to the county health department of the county
tYpe:nI- where constructed.
i
Revised 2-22-2016
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources