GW1--06215_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-f1 For Internal Use Only: i. .
1.,W ell Contractor Information:
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FROM TO DESCRIPTION
Well Contractor Name I 2.® i4 /,�ji.ervi
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NC Well Contractor Certification NumberfrIN ef!'•!:C G.N US'�n�yY•
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,1�5OI311`131�G�tfi0lflPrlf4/ .lii�Sf� �ti��1s�t?]1�L3�VTR`.�t��A�lat_A�1@ "'.z:;:7_:-,p�%.t'r�Gr a -p®�` L U ali ip 6 t FRo" -, TO _ 7lbuifL�fEfc ilittl4grSS 7ERL1L _
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.0 Weil Name `. t f[ GlilakiliING. glxiiedauot r''7.. Xa=c4 4r a" .'
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2.Well Construction Perndt#: FROM TO DIAMETER THICKNESS i<tATFHioT
List all applicable well construction permits(i.e.UJC County,State,Variance,etc.) it. ft. In.
3.Well Use(check well use): ft. it. in.
Water Supply We ll: 9 - 'sy. Af r . �Yl I, t. Vr7 1:,.yy-ae 16.7r -vaik
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I4rRM T .-- tD1AlizT} sLoTCTRF. rg.TRIK.NiE,S "—MAERa :
❑Agricultural Ol4unicipal/Public ,1 ft, ft. In t.
❑Ge ciothermal(Heating/Cooling Supply) esidentia1 Water Supply(single) ft. ft. In.
In ' ,
Dlndustrial/Commeroiat °Residential Water Supply(shared) �y�:p /v Y( r �ru:�•�r
l•7gitRati z 1.5.5 K li�t,� ,7
°Irrigation Dwells>100,000 GPD 'FROM TO MATERIAL EI(PLACE~E MEMO&AMOUNT
Non-Water Supply Well: 0 n Z© >t 10€041414_ Ira 4 1-
Cl Monitoring °Recovery it. it. U
Injection Well: R. ft.
°Aquifer ti
Recharge °Groundwater Remediaon Y
g fi;f9.s9 1!ip7t f�VE1 'AUlf(a�RPkeUbl F_ ���`a�r ct �. A �5? ^=
i�rRtnrarn.and RPfflvnro n Salinity'Ramer room I TA 1 mterAl r ir, I EMPLACRM!NT snrennn
°Aquifer Test ❑Stormwater Drainage 1t `
DLxperitnental Technology °Subsidence Control -ft. ,
❑Geothermal(Closed Loop) °Tracer to iutigG:i t:C:{ati ckiiidiikuadiertsifriea`U&rykl' ti, «•.�rka. u'r:Z. £
°GeotheImlal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM 1O DESCRIPTION(color,hardness,soWmek typy grata size ere)
4.Date Wel(s)Completed: a'd-0j Well ID# Si) ft' too n' . b o, 15 Lk
_ Sa; VellLocati9p: l .rib it. •54 it._ rail 4' tacIC :
Toc,1 e( nantie./...e it, "it.{
- Facility/Owner Name Facility IDtt(if applicable) It' n R lP rm:\ ,/ ; �'N
, it.;. tr,:
Physical A ,City and Zip I I is St N '� 5 2023
`/ ®•1ddress 1 p st'V I� I. L >< lei •'�i3;{?4`(',"�5 p, f lwart,+tttl.+. - �r``l'�!d .Tr�tt'�y H.+c`;::�'}`�xt
r --4--ks.vr+ eii P"r':' s9 Una
County Parcel Identification No.(PIN) fir° '_''J
5b.L:a.._.de anti 1m,nitn,lo in itnerPoriminrrtpc/nernmin nr optimal decrees
Of well field,oneiationg is suffiete 22.Certification:
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6.Is(are)the well(s): ®Permanent or °Temporary Signature :tided Well Con ctor' Date
By ' this form,I hereby certify that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or llo 1SA NCAC 02C.0100 or 1SA NCAC 02C 10200 Well Construction Standards and that a copy
.(fib's 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:
S.FOY CeoprobetDIAT or Closed-Loop Geotherma:.Vels having the sem: +m nai' "ii..ua v_ry av_ _,r.w y-n�-e.:_i:r- .:.X.c•tta-ai=«mil. -1-..-
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construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See O'ef in Remarks Bea).You may also attach addifional pages if necessary.
drilled: 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /4 an (B') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths{/'different(example-9©200'and IQ100)
10.Static water level below top of casing: 10 (f.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater love!is above casing,use oInformation Processing Unit, Raleigh,NC 27699-1617
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iL ..,,t.,aa atnwento,.. 1A fin.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
rites41.11,[p?q 7vt4.__n, rc,�r NC-i2 c�r•-.•-:..,r
12.Well construction method: air r r Q i d 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where'installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
/'d� „L I O w Permit Prograna,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /J l LI Method of test:. f
13b.Disinfectiontype: V17 '` Amount: (l2 lib
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