GW1--07870_Well Construction - GW1_20231205

I
WELL CONSTRUCTION RECORD (GW-4) For Internal Use Only:
1.Well Contractor Information:
:1-4,.00 f
Well Contractor Name ii, Otwl-e, ,
FROM TO DESCRIPTION
0-�1g A 13, Sft q P m
•
NC Well Contractor Certification Number
_1 __ - <i?is%+n am,+nsrxk dtrRna,a_a;e.^+'.9etir-!«v..vs•i:.ni+_':7ie.:e-v�.:-.,:•,.r•,,srM1r,:...�..-,:..
FROM TO DHA,I TER TRICJCVM MATERIAL ..
O ra(Al tbo kd p RA 1 4 ca,i t r, ft. `Q
Company Name ,( �7 �y.. ��y� it. in. yg� �t�V ��E(�
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2.Well Construction Periidt#: 1 . ' FROM TO DIAMETER ,THICKNESS MATERIAL
List all applicable well construction permits(I e,UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use); It. ft. in.
n wwm�w
WaterSupplyWell: IIAQLlt �n� �3t7 wt { i1 L �+r �4 3!� 5~ d.Fi� cC?y P�1FROM a, I TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL ,.
❑A nricnitnral OMunininal/Pnhlin u ,
OGeothermal(Heating/Cooling Supply) I ft esidential Water Supply(single) ' 1 it, 1 1
in I
Dlndustrial/Commercial °Residential Water Supply(shared) r 1!!`RorTf a mm,so, T tx�J:NNNO ,;a,,-1- s, W L,a
°irrigation °Wells>100,000 GPD PROM TO MATERIAL EMFLACEMENTAETHOD t&AMOUNT
1D
Non-Water Supply Well: 0 it it4 in j
r-air 1- 7
°Monitoring °Recovery it. R
Injection Well: -
°Aquifer Recharge °Groundwater Remediation ft. ,
;�+wtf�s�rer5 •yam ,,,,,wry ....
i ilQmaifar•:Ctn..oaA anti l2 nnnvn..a rio..!:..te-..D..?:_d t+-Pn14101,v': .ppew-'.'•. itii?iEEBfIERt '$4-�r.;`s' $e$5:7,cY.a:._9a.;.y�rz:3;v.:-;=..',..
...-1-_-::,--, _,, .v ! ava4awc,n,+ _ _ _ ! k9,iiri...W.EEVAbe41'Auvrl0
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DAquiferTesit
OStormwater Drainage it. ' ft.
°Experimental Technology [Subsidence Control ft. ft. 1 I .
°Geothermal(Closed Loop) OTracer AIII3 7F t'(L'#> aiiic7C dWe#tal:itlio ti ii gr'yyl� X •i3§.'w F
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM To DESCRIP7T N feeler,hardpan,sal/husk ek type,arsta sly,eta)
0 ft"
4.Date Well(s)Completed:161 ''3 Well ID* 30 ft. it. c,)t1
5a.Well Locaitaon: I tP.a'o f' I f) rPd A a°-0 il ' li'aa e
jta n I win vs (knit, y ft. ft.
Facility/Owner Name Facility lD#(if applicable) it. it. ]�
43i7 5.4(eIPYI St: 64f/1g ri a.15 .9 it. ft.
Miyake!Address,City,and Zip it it. fi
1► a lct- 1(3. 3ii ),%a x- ,� • s� t r.3_.
� :. 3 +L 5'...�. -s.i. "_� t e�'.'TI„'az,7 kk, .*fir;
County Parcel Identification No.(PIN) DWG/'
sh_E.nii4nda anti In:ait- in in elnrevnag/.,.t«..r.. /........_a_•_'.,_-`.._ . . -
(ifrwtt zitid,one istrt(mg is sui tciere) a 1
22.Certification:
A N W G i0 - - .6.Is(are)the well(s): �1Permanent or °Temporary Si!.. ` ofCeitified WellfAII6O1
tractor ' Date
7.Is this a repair to an existingwell: °Yea or `l . 'WV this form,Ihereby ear*that th fwell(s)was(were)consoucted in accomlance with
pal NCAC 02C.0100 or 1SA 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 1t21 remarks section or on the back of thlsform.
23.Site cline-rem nr vagltinnal wain aa}aila.
... '•-•"- 1' "=� ;s wren;h.....,..,....„-•..-_-___ Y nil may lien the hank of thie roe to nrnvirie aridifinnal wPi1 rnnet actin±l p
....k......,. :i a4,a4 sa.ew
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
® 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i
For multiple wells list all depths if different(example-3©20� (ft.0''and 2@l00) (f t') Submlt this GW 1 within 30 days of well completion per the following:
! 24a. For All Wells: Original form Division of Water Resources (DWR),
10.Static water level below top of casing: AIf water level is above casing use"+' ) Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
11_-iinrnhn em v le. ia ©to . fa.,a 241t. 'Rm.e-ninr binn'iSrnFlc. ..../a. .a ra., 'nr! rr..a _--_-__._''.
12.Well construction method: a i r rid a> i 24c.For Water Supply and Open-Loop'Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) p y
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over
�° hi p 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) , hi-i� Method of test: Permit Program,lbl]'MSC,Raleigh,NC 27699-1611
13b.Disinfection type: ►1 Amount:jJ 2 (b