GW1--06747_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .
1.Well Contractor Information:
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g'as 0 e L Poo�`�„/ T,ot'VFr,#l',I' R�L(.rll$ .:,,2 3 t�4,:' } `� '., :. 'hid,�.,a: ��.r,. ; ::i r .; >ti
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Well Contractor Name FROM TO DESCRIPTION
� l 1 .A ft. �!y ft. /�' i I A1
4 ft. r 2"v0 ft. /lc j�; prig
NC Well Contractor Certification Number !'1
6 �S.;;UTTfER.Ci1SING(formitlh�a9e s)OR;L3IYER%(ICap licablej ;..
�`e a 1 Pooki �I FROM TO DIAMETER THICKNESS 1'MATERIAL
J� ft ft in. A f
Company Name ��( V
OV P - 11_ 3 .:Id.TF3NEReA5TNG:. it.t INGF,(g ntberma:dosed:loa1r}_,.s Wi r:`,,
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17r5CIt. N ti w: ,N . *..'=g` :?.' .. , r 1 1 z
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. ft. in.
1
❑Geothermal(Heating/Cooling Supply) igResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,18,GRU`UT+.ox SW,v, .Toof ? ..'` v..y.~ r.. r '1u,,?.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,
Non-Water Supply Well: f) ft. 2.0 ft. b�--o 11 r 3 ray flji
[Monitoring ❑Recovery it. ft. i. 4 E h ff
Injection Well: ft. it •
❑Aquifer Recharge ❑Groundwater Remediation brit 5
9 SSAi?W/GRAVELPACK3(d"a)Spllca „ .*g.:i <..MOAWO:x .< ,.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It. , ft.
❑Experimental Technology ❑Subsidence Control ft. ft. ,
❑Geothermal(Closed Loop) ❑Tracer ,2oa'IIRIElititGg`1 QG':(alto'cti•.addifzonalsht:ets it`neoessa't+ylV .,. 4 eta`+`'>in;r.;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,Arab sire etc.)
4.Date Well(s)Completed: 1 (Q—a.a Well ID# B 0 ft. i it ft. £a'k f®tA ti
5a.Well Location: A i i q 00 ft. i 6 0 ft. q rt� ,Z (ec ,
ft. ft.
Facility/Owner(NAam�e R ( aFacilAi�ty ID/#�(if applicable) `_'� ''350 tiv II(?) l i!rt&e l 1V of imo,4 1,60 ft. ft. 0 1 L0'23
Physical Address,City,
and Zip 1 ft. ft. it?`.;, :'`+:j:`� ;o,, .,,M,n i 1-'1
War!.�{I (CM i1 ltaEMARICS ?g?W a t ^-s'�.04:t 8ZW' VAV3-'-ititiAi: . ?.a5?k 1<.1:;.
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweil field,one lat/long is sufficient) 22.Cer,'•.ea i tin:
N W 741, 1/ / % .7ZC-23
6.Is(are)the well(s): 'Permanent or ❑Temporary Si_ Certified Well Con ctor -Date
By signing this form,I hereby rhfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: :Yes or Cho ISA NCAC 02C.0100 or ISA NCAC 02C.0200 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.
23.Site diagram or additional well details:
8 ice,.f_e"rche' PT er rtneed-7 oo Geothermai Wells hav n ,he gt „mr_ ' You may use the back of this page to provide additional well construction info
-r-_ -'� - " _ (add"See Over'iri Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days off well completion per the following:
For multiple wells list all depths if different(example-31(29
00'and 2(g100)
10.Static water level below top of casing: 1-0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
DO r
Program,1636 MSC,Raleigh,NC 27699-I636
12.Well construction method: a. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) c1 t� Method of test: 1 b Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: il Amount: ' 2' lb v
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018