GW1--01147_Well Construction - GW1_20240219

. • •Pri)nf Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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all'd Cat vfn r _ - IA VYATP7ii TONES !.x
FROM TO DESCRIPTION
Well Contractor Name • ft. ft.
Z136 `A ft. rt.
•
NC Well Contractor Certification Number ;r1.5 OU.T.p1r0ASiNGv(for mul(ikifiedtiVe116)A€'•DINDRs(tf ep 1ic8614 -
I �-7 /� FROM TO DIAMETER THICKNESS MATERIAL
�C�t� S � �I (i'LI�CY I✓U%t11'1 l�(1. I f' R 5 ft O' S in. SYA2I PVC
Company Nadia '/�/ `� J Z j ( �y :16 INNER_Gd51NG`•.QR�'Pi1BINGf�totlier nahclosedtlo4p) " G _.
2.Well Construction Permit#: ,v AV/.0 / •- D 1"l el 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): ft. ft. ' In.
A7S.t7REEN -,'_'a:. _ry .,=• <.. :_
Water Supply Well: FROM 'TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DI Municipal/Public ft. ft. •In.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft, I In.
Industrial/Commercial OResidential Water Supply(shared) °a18 OROt)R`
.•;Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 0 ft. aQ ft. 3 pj i-o - , i 0 i3GcL�-0�G(2 red
Monitoring ' Recovery n. ft. a
Injection Well; •
• ft. ft.
Aquifer Recharge OGroundwater Remediation
<19.:SAND/.GRAVEL'PACK(ifeepp1Icsble).
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test s. OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control R. ft. ,
Geothermal(Closed Loop) Tracer T 201 DRfE1;MG EC:Gl(attaoir;dBltlonalfiheetb Ifnecelsary) :'`_='==' -.: :
FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. �4J. rt. i S jay of ry ,(�{ �1
4.Date Well(s)Coppleted: a /21+ Well ID# fate_ tt' 3(g�� it' �i�Yxvlr T�
5a.Well Location: It. It. 1
CMi H.1 ome.,S ft. ft. P-'• r.•7:II y 4. ...G_./,
Facility/Owner Name Facility IDll(if applicable)
171 0I d MGare,sbcir® Ad ft. ft. FEB 1 9-2024
Ph ical Address,� n/ City, rt. rt.
and Zip f M..
21 rugm 72KS f i hZt1 ,,„ .,,...•r 7."s...Y..-
PC(Ate kb),ri tVi0.:30G. •
County Parcel Identification No.(PIN) _ -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Cer fication:
3 5.2 599 N ._g1 .7? 55 7
2 , /,L "6.Is(are)the well(s)[, 'ermanent or Temporary Sig/ / 24
re of Certified Well Contractor// Date
ily signing this form,I hereby cert(/'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or 13No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well 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.
repair under 021 remarks section or on the back of this 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed; Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
• i
9.Total well depth below land surface: S (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdIerent(example-3®200'and 2®100') construction to the following: •
10.Static water level below top of casing: Go (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"+"" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: jlmaddition to sending the form to the address in 24a
L above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ' lqt3•7 G�►"3/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
(-1 d Method of test: A i r , 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:01.If/t^IVI i. Amount: 2 C.upS completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016