GW1--06808_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY: •
1.Well Contractor Information:
�`l`G 1"\• l'M`t.•&1 I 1,5 114.W 1,ft,ZON1:S,'::}•-ra;•;n, t•a.:•:. ::•:.' •:'1•:::;:: ;::: a_:_:.•..•_ :r ...
FROM TO DESCRIPTION
Well Contractor Name 0 ft• zoom zit /I;k�
a o38 - A a soft. &Oo ft. 1TY46 ki-d
NC Wall Contractor Cerii Won Number .;15•OUTEWCASING..'{fur'tnulti+'cascil.wdlls'OR'L•iNER:'if a..liduble•`:'( n 1 :;1:
1Itf , I� / / e ///�� FROM TO DIAMETER' THICKNFSS b.gRIAL�� Sy-aJJ/t. /CU<' Q / ft. I .4 U. /_ t(ee in. f ,
Company Name 1 eo w��w�l Y
�y !16r•INNER.GCSING`.ORTionNa'fnentltc- ins.••14tin ..!! ?;:'
` 7�0� I FROM TO DIAMETER. - TIiICIcNESS MATERIAL.•......... .•.•2.Well Construction Permit#: V I I ft. ft. in.
List all applicable well construction permits(i.e.Camry,State,Variance,etc.)
ft, ft. ' 'in,
3.Well Use(check well use):
`A7:SOREENd •:7: i:':r.'•... . ..!:'d°•�`•:+'i''••"':•:..,�v:;e.. •:•,:�.;•._.,..,•,•:c:..,.;r:
1 Well
PP Y FROM TO DIAMET SLOT SIZE THICKNESS MATERIAL
Water Su
❑Agricultural OMunicipal/Public ft ft. in
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft In
❑Industrial/Commercial ❑Residential Water Supply(shared) 181 GROAT':: '..r:•;:.:.:::''''':;.•.::Ur: .....: ,: r".A.•::•. ,:.
❑Irrigation PROM TO MATERIAL E CEAlENTh1ETH011 S AMOUNT
Non-Water Supply'Well:
it• .2s- ft. /.l_1 L _i �b 6AV
❑Monitoring ❑Recovery ft. ft• /I•,__lQ L � f -
Injection Well: ft. •ft. ( � i j���
uiferRechar e '
❑A
q g ❑GroundwaterRemediation .197SAND/GRAVEL'PACiv:(iradplicnble)*Y..E.•: -..::: •.,Y!':.::,,,;.,.-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft I
❑A Test ormwater Drainage .
uiferest ❑St
❑Experimental Technology ❑Subsidence Control R' ft.
❑Geolhcrmal(ClosedLoop) OTracer ••20:DR1LLINGL•OG(aitnei;,adldoriol'cbcets•ifuceossurv)`:':'.:: •.••,s.,r•s:.;: ,,:::.';.?
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,ralUtnal rypq>min site,etc.)
4.Date Well(s)Completed: 5 ' 2.3 - zo 2,3 ibC". 0.26 ft Rruked (AP p)0c -,
5.Well Location: '
ChArleS l��WAAW ft. Via- ft.
Facility/OwnerNamct�S tt• ` Ob f6 _.CD/j J f/6 ,L/ •
- I p f Facility IDH(if applicable) V CJ Qi I LS/tr.._
fr0l��l Rd - O4tcbo ft. ft. �' T'. {
Physical Address,City,an Zip "6,...1 -
._5"/d 0 S 4 CO 1.4`/7// 21.`•RFJ►1ARIC5 • , 8
Ot`T
2Q23:.,:
County Parcel Identification No.(PIN) ,
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: irlf,z a:..',.;D Pr ""``,72.74•1 t'3;1
(if well field,one llayt/long is sufficient) 22.Certification: G: t�`$S'�f
r5s° r/ ,b N a 8�` IA /�
W , tor
.1J-23 -z�3
6.Is(are)the well(s): ermaneut or ❑Temporary + 1°turc of Certified Well Contractor Dat •
a
� By signing this fern,,I hereby certify Thai the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: py� or Oit(o with ISANCAC 02C.0100 or ISANCAC 02C:0200 IVeil Construction Standards and that a
If this Is a repair,Jill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
i
repair under b21 remarks section or on the back of this form. 23.Site diagram or additional well details: •
¢¢ You may use the back of this page to provide additional well site details or well
8.•Number'of wells constructed: eRJ t� construction details. You may also attach additional pages if necessary.
For,multiple Injection or non-Crater supply wells ONLY with the some construction,you can
submit one form.
24.Submittal Instructions:
9.Total well depth below land surface: dao t (It) 24a. For All Wells: Submit this form within 30 days of completion of well
For undtlple wells list all depths if different(example-3©200'and 2O 100
) construction to the following: •
10.Static water level below top of casing: �'1`J•I (ft.) Division of Water Quality,'Information Processing Unit,
•
!firmer level Is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: •
(in.) •24b.For Injection Wells: In addition Ito sending the form to the address in 24a
12.Well construction method: 1 l� 1'
p,-•,.idr-fr/ above, also submit a copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t i
13a.Yield(gpm) Method of test: fo f-d 24c.For Water Sunaly Sr Geothermal Wells: In addition to sending the form to
13b.Disinfection 'may' y e the address(es) above, also submit one copy of this form within 30 days of
t1'Pe: '��lets Amountt� /t�A completion of well construction to the county health department,of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality)
Revised Ian.2013