GW1--06208_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I •
1.WelI Contractor rnfdrmation:
1 i
1
1d L 5 0 tt ro
/ 'b ..14 v4?ATER;i'i0i!TESiw.-mcm...>,wokzwA, ,ro r. _ :.
W ell Contractor Name FROM TO DESCRIP,TION
:1 I ft. d&a ft. 30 I{q; r^hi
ft. ft. 111
NC Well Contractor Certificatio Number x5,Af3sPEg Cz#gI�IG Cfot mint►-casein veUs)012->;I1KER:(ifap L'aabI ,, ;.0
t 4 ' FROM TO/� DIAMETER THICKNESS MATERIAL a
1r�W Q OD t9/ 01.11. � '�.. 31 ft. �FJ�ft. in. 0 I. t�A A``�^to
Company Name ;
rb�iilTl+lER,e,:ASIN:G.OZZ'rTCFBIIYOWutGermaTclosed-loop)>'0 .rW5MO„`..t.
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2.Well Construction Permit#: / 0 6 1 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): ft ft in.
Water Supply Well: :47:;SCREEIIO.M t,.ti 0g,z,. Mcx . .`... ,+a4?,:.:, ,:,<r,,.,,
FROM TO DIAMETERY I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑I4unicipaUPublic ft. ft. in!
OGetithermal(Heating/Cooling Supply.) ticResidential Water Supply(single) b.- ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) .-18 Gt Ot11' ,y Y:„.; , - ,.i # , 4; , p" ;�. : :-
❑Irrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft. 1.0 tt. bEh" vilfe j rthert j.
❑Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
:19:iSA11i)167 A FlL:7'At'Iegitjiplicfil Ie7`._.:if :_ •.< ,. .,r3 __ , W:.w
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage `ft'
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❑Experimental Technology ❑Subsidence Control ,, -ft., :ft. - .
❑Geothermal(Closed Loop) OTracer I2D IIHILL`x1YOL13t:(attatfi=aliaitteliits"heets:ifneeesaarv,.)s` M°::,r '.: -may ,=
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 1 ❑Other(explain under#21 Remarks) p� IL
X0 ft. S�� /
4.Date Well(s)Completed:l'�314-3-3 Well ID# $t!o ft- /A p ft. j r 4 41/ r®`.A�
5a.Well
}Location: �/ st ft. ft. r' r�, .3 ,.....`,
° i �,1 Ct/Pi . ft
, ` Z 1...i,✓{..i t i ?"*" f; '
-Facilility/Owner[Name
-i°-��� J Facility ID#(if applicable) Q H. . R' - SF 2023
g d 4,5- 41 of ik Eft, LYE S io 5 r € i 51.1 9 ft ft. t
1 ,
ft. ft. - Iruryari;aii:$I r7' ,9
;,fYA-'t l�f
Physical Address,City,and Zip ��l]t/J� (B *fvtitir., ,
-Fr 4h,-t A`tl I V L s pi—®@cil f`a1 sat �i i ,v sgz 4`'c s 4 fylj,, j^ ,
Ar 11' aJiSA t.f,..L.;,e: Y1.x. .r.:SG x_.... n-..as..H,�+..f .... �.-•.u'��v.Z..
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IN ;
(if well field,one lat/long is suf cient) 22 a tion: 11‘"—
*+, ,f 9
.N W / 1" �,. 7-2 /P :tL,J
Is(are)the well(s): l�Permanent or OTemporary
f Ce ' d ell acto"r Date.
6.Is( )
By 'ring this form,I herJy certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 15 NCAC 02C.0100 or ISA NCAC 0240200 Well Construction Standards and that a copy
If this is a repair,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 remarks section or on the back of this form. Y
23.Site diagram or additional well'details:
,._r __...., svvr....rt,...oa_r.,.,,,r_o.,+t,o..,,,,.r work hav;,g ti„c„ You may use the back of this page to provide additional well construction info
1,,,,,,, _ _ ,,,,- __r ____-. _—._ .._ p f --- (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1 24,SUBMITTAL INSTRUCTIONS
9.TotaI well depth below land surface: 0,0 (ft:)
For multiple wells list all depths If different(example-3©200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 1 ® „, s 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1.
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy ito DWR,Underground Injection Control(MC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: air ra ai 24c.For Water Supply and I Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush,etc.) county environmental health departtitent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD: Copy to DWR,CCPCUA
t 4 V/
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 30 Method of test: pp
13b.Disinfection type: V! ° I) Amount: 1 I2 Cb i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018