GW1--07179_Well Construction - GW1_20231101

WELL CONSTRUCTION RECORD(GW-1) For Internal:Use Only:
1.} 11 Contractor Information:
C/jh/ .d Comp 14M ,
fi(V l ipl'ov ATTi'R"+.. alr�Sf`F+.`;:'iA`netri5dStt,1 ?AVir,'ii..".W,.£yz,/, i is 611:....:.Y `yirf3
Well Contractor Name - FROM TO DESCRIPTION
6. 16 ft. ft.
N Well Contractor Certification Number n =1Sfio11TER gASINGt(foir iiiiili '�irsidtpallli)iORIBINE$?(Ifitin ileablisr , z1
G Weil/�i i )m C� FROM TO DIAMETER TDICE:NESS MATERIAL
P �/V ` el {{ �O j ft. 160 ft• -1 ,5 ii. 17(12.1 PVC
Company Name 1101NNE 't'Z"ASIP1'C1OR' UBIT!Gt(geotherimlarelolled Mini)ak :i'"$.,E'1WW0zi
2.Well Construction Permit#:Y.4.1 I-O 7-2152 3 1"19 751 FROM• TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. j' in. -
3.Well Use(check well use): • ft ft. 1 • in
Water Supply Well: wltl+iiS: IN it :i'_lk4Ifl S?;;k v zv e`'r,St. l z;�0'"c: r.A'Ifni _Y-4
PP Y FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. ' in.
Geothermal(Heating/Cooling Supply) it Residential Water Supply(single) ft. ft, In.
IndustriaUCommercial " - DResidential Water SupPlY(shared) 5 GRo , r t%-N g:,y± . y a.� •K< „ m-, :t,,,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2,0 ft. I✓e)ti icn 1 P r U` ay
Monitoring [Recovery ft. ft. Q
Injection Well: ft. ft.,.
Aquifer Recharge DGroundwater Remediation K19 SAt IG RIPPAtfrKipf'ppAlleabl j0 41.1 1 70 AVX- .R ,+:z V"'`
Aquifer Storage and Recovery ' ' DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test \ 1 D Stormwater Drainage ft, ft. I
Experimental Technology ',I., 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer L20VDRIL1i 1GIOGi(a(tachraa'diUonil111 iii>irfiYie'tediaiy)lt:,e ate ze'>;'gd}.•t �>
FROM To DESCRIPTION(
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) (color,badness,eolUroca type,grain elze,etc.)
© ft. 150 ft. C1 ay
4.Date Well(s)Completed: 1 O/0 f.'i.23 Well ID# 16 1 ft. 3 OS ft. 6 Girt qt.,
a.Well Location: J� r ) /1 /(� ft. ft. _
kcio [-)oiQ 1 Vi r eo. r ft. ft.
i. :, r._. r & ,4 t f. 'ti
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4v.^&u i; tl� r_ :+ ii
- WOO Deft P d i C/a r e,niont,/I/C sc,1C7 ft. ft. NOV , 2023
P sical Address,City,and Zip 1
J� :211 iMARK6/ - !r;`y:1�s tr#6P-"5 tigg {err .;:r it �:^ ,,k:!
j yi .1
Country({H/ Parcel Identification No.(PIN) - rJ�' i'a OS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• ' I
(if well field,one is sufficient) 22.Ce don:
35, 7992.6 N -g1.13/05 W ,y, /0�-,,
_ _
t St lure Oker ied Well Contmotor - Date - -
6.Is(are)the well(s)69Permanent or DTemporary
By signing this form,I hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or ifiNo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thls form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
i ..
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'O 5 (ft.) 24a. For All Wells: Submit]this form within 30 days of completion of well
For multiple.wells list all depths iifd fferent(example-3@200'and 2@100) construction to the following: '
10.Static water level below top of casing:• 65 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b.For Infection Wells: In(addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: go 4-0er construction to the following: I -
(i.e.auger,rotary,cable,direct push,etc.)'
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLYY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .✓ Method of test: A-i r 24c.For Water Supply&Infection Wells: In addition to sending the form to
/�
the address submit
es) above, also one copy of this form within 30 days of
13b.Disinfection type:C' III 1-Wlrl VI6 Amount: 2.(r.Uns completion of well construction to the county health department of the county
I where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ces Revised 2-22-2016