GW1--06736_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD CGW4) For Internal Use Only: '
LWeil.Contractor Inform on::) .:
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FROM TO DESCRIPTION
Well Contactor'Name
-�� V � ft' 35 I fYY1 .
NC WeII Contractor CrtiffcatibitNtunbex • titikt aAC 4 r it"c diti -Sra• fs AI-'' ��,yg tPaeif+u?ura 5' tc:.re, '•`.
n ( f) 1�T?n%�ti",_i. �- . .te :.t.
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V ➢�1 p %IC
IL011y 1n. 1 � 7app,,,vY 4t10 / G.tGt�4,CompanyName <l �Il ri+ 'r tlida itt5��wti�t-R.�1' 'tit Sr�}�,
2.Well Construction Permit th `�i 13 - 0010 FROM TO DIAMETER THICKNESS MAT.•
List all applicable well crnuaowetion permits(Le.UIC,County,State,Variance,etc.) it. ft. U.
3.Well Use(check well use): n' !u'
Water Supply.Well: 1 stan�n Iron areasaraia t-ci.,;,;;;su /.r.st
DA ricultural Ci iutucipauPaoiia �i its. j r1 fi
j I
°Geothermal(Heating/Cooling Supply) IResldeatial Water Supply(single) In.
❑IndnBMal/Commercial CResidential Water Supply(shared)
A u • it�A.4«R3'%''f'.il'+��1,'`.aokiY3;t.°+'a' ':�rWY,....N.k:`�'•`'Ftr:T,iji•-'a�.?`v:,�r�'•.:
:
Mitigation Melts>100,000 GPD FROM TO ,MA EMPLACEMENTMRTHOD AMOUNT
Non-Water Supply Well: 0 it lO fr. f OI'f tat)li jra.V j 4ii
°Mo ' i _ °Recovery ft, f, ezebe N
Infection Well:
DAquifer Rechar a C7Grouadwater Remedietian ft. .
• P if,TcZYs3i v 9:th!,Aeu :g ri i, Y"--z i,;:v3� . n.+i s ,H:- :a
GAqutfer Storage and Recovery CISalinity Harrier ,.,+.... "� , � I' 1 i ` "
,
ClAquifer Test CDStormwater Drainage it. :t.
Dlxpe rimental Technology °Subsidence Control it. .
❑Geothermal(Closed Loop) OTracer � i ah t rigretki rLIV:ea,,.'i`:t .yi y
FROM TO DF.9CMPTION(color,budnas,talikeek rim gen.• sto
aC9wthermai(HeatinWCooling °Other(explain under#21 Remarks G 4' .
4.Date Well(s)Completed:I9lei:74
1-3 Well IDfi b n• ,S p IL 43 t +el tO C k.
Sa.FAT Location: i. _ , . r; cj
60 kly P av IS
Facility/Ownedd lame i Facility IDA(if applicable) 1t• fr. U I2
4 io7 wdoLl:r sir-tie. e,�Jrc. r(/l ��17?
t6, ft: 11;;, , :: ,a,.
Physical Address,City.end Zip #t. ft. ,,,,:i L.,- -:-. ,�i�-
Or o� e. if705555':.35 ri�> l.;= . �m�oo kao v,< r . :,..t,
County U Parcel Identification No,(PIN) .:
Sb.Latitude and longitude in degrees/minutes/seconds or decimal de. p,.t• __ F
(dweltAdd,one faulting is suficiemj 22.CertiBcation:
Lofty: kll 433
6.Is(are)the well(s): liermanent or []Temporary si of certified Well Da
fiyal ming this form Thereby cert&that thewall(s)was(+were)constructed in accwraance with
7.Is this a repair to an existing well: EYe3 or dirt ISA NCAC 02C.0100 or 1SA NOW 02C.0200 Well Construction Standards and la at a copy
If this Is a repair,f ll out brown well construction Information and explain the nature of the afihis record has beengmvidedto the well anmer
rnnnir vztr7dr.J71 re,,, _varlinn OP nri dig Mick eftltfn fjgPL -
23:Site'diagram or additional well aids: •
un.w•-:,_=Y t.:z .�"..' :1. al:T uting.tlia arca: 'Tim may iise mnsnlr e ni'irk mita.to nmv rte Ai ii"tfrnnca wnll rnnc retionl i o
constnrctio
��`: .c ''r•W1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
�only I G
drilled: (� 7.4,SUBMITTAL INSTRUCTIONS
9.Total wall depth below land surface: 1- (ft,)
For multiple wells list all depths ifdi ferent(example-3@200'and 2tlo0) Submit this GW-1 within 30 days of well completion per the following.
(R•) 24a. For AU Walls: Original form to Division of Water Resources (DWR),
10.Static venter level below top of easing: �0
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
limier level is above casing,use"+"
Li.Borehole diameter: .(in.) 24b.For Injection Wells:Copy to DWR,'Jnde Underground injection Control WC)
�^ Fa nay rs A➢RCr,T2etni,1, IT /799-AA2it
12.Well construction inethodi Q a( r 6 rr 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusk etc) conilt),snvironmental health department o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GM:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
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b I( ) Permit Program,1611 MSC,Raleigh,NC 277699-161 I