GW1-2023-00538_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Info /a�tiHo Tl�/V .:`er4�iyYA-u�'P.,1�.iV4�ct�.`$..z_J '.�•'iY4o�,x- IL.�r ��a.f.: .ri�.,."x.1.,r }�'h:+a lzv:k..ix:.-'Caa
Well Co tractor Name FROM TO DESCRIPTION'
ft. use ft - ,V
ft. ft
NC*eh Contractor Certification tnber
`' ��.15 OTI,xERCASINt`: fortndlt=cad .Fells`OR�` FER�iif e'lice6le �''� ':.,.�:..,,x•
y--f. O��� lJ�� FROM ft TO DIAMETER THICKNESS MATERIAL
� t
1 �l I in
,::,.::i,»:�;�»:r:» _ ��'6xI1tSl�TER=SAS LWGbR�F11I3IlVt'r c`at6errneleiused�oo ,�"� �;."e..�a`s-r,
2.Well Construction Permit#: ��' 6 Q Q S C5 FROM TO I QDIAMETKIC I THICKNESS IER1AL
List all applicable well construction permits fl.e.UIC,Counq,,State,Variance,etc.) ft. ft In.
3.Well Use(check well use): it. ft. in.
Water Supply Well:
FROM TO I DIAMETER I SLOTSIZE THICICMS MATERIAL.
❑Agricultural ❑ unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Zsidential Water Supply(single) g n, in.
i
r1Tw1natria1/("Ammarria1 flRacidential Water Gnnn1V-(eharPAl >. .......__�_.. . ..�:,,., -......,:..:<. .:...-..aM.. M..-.�_...__..._ -.�._ _ :....:..
❑hri ation ❑Wells>100,000 GPD FROM z TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
-❑Monitoring ❑Recovery ft. ft'
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
1'9:;stlfiTFlC'RA :1!eC13 .lf`a Tti:iilale
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage' ft ft.
r'IFvnorimantoT Tenlinnlnmr rlCnhcidenra('nntrnl ft. ft
❑Geothermal(Closed Loop) []Tracer 'xil;l]l1iTIs Gl attachaitditton s'eetsifidcess ? k >',y?{ r: ". ;" �
❑Geothermal(Heating/Cooling Coolin Return ❑Other lain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock rain size,et,(H 1 g ) ( ) I er. ft. ft.
4.Date Well(s)Completed: ! D 41— Well ID# Q ft L) ft
rt. �, b ft. n 4 L, u
5a. ell,�tL'ocya�tions�/ "�'�� b
ft. ft. _
Fa ility/Owner Name Facility ID#(if applicable) ft ft
el
�,r r
L
rt. ft.
Physicaa/1�V111fddtess,C' ,and Zip ft.
n•� S� I 3 6 O �tiJ.R Id Ry .{{��yyaajj�,j;tr• Z ���.yy„C..5�:.i 2 'v�:e.tL Fa� R .�"{''(} t.SF+1 �'r{k+a'./F'F -.'. ir:..,t$..� I Y I'�JY i Ilc;N„� . ..,R :?.'�tJ f F:•l
County Parcel Identification No.(PIN)•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one IaUlong is sufficient) 22.C rti$cation
6.Is(are)the well(s): ermanent or [:]Temporary ' attire of Certified W$11 Contractor Date
lyll.sy signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o ISA NCAC 02C.0100 ar•15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,Jill out known well construction Information and explain the nature of the of this record has been provided to the well owner.
repair under#21 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: .� onnarrmr.r Taremn n�miiv�}c
9.Total well depth below land surface: / V 67 A) Submit this GW-1 within 30 days of well completion per the following: F
For multiple wells list all depths ifdier•ent(example-3@200'and 2@100')
24a. For All Wells.;Original form; to Division of Water Resources (D , ,>
10.Static water level below top of casing: (fti) Information Proces'dbg Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" .'
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)'
' �� rb Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �! 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
ti.a.auaer.rntnrv.rahre_direct nuch-etc.) __ -TL__2 -._u_�
4.
FOR WATER SUPPLY WELLS ONLY: / 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) °"
�]5 Method of te t: l pM/ Permit Program,1611 MSC,Raleigh,!NC 27699-1611
s f -
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018