GW1--01275_Well Construction - GW1_20240229

WE'LL CON S1_KULiUUlNN MALUw lliVW'-. ) ` Norinternal Use'Unly:
•
1.Well Contractor Information:
J/�j �,yp� qpp��� ,�t Asry., 9�.,1.s Sc y 4. S,
a 5®• G ®O I 1!1!to'.T•Eris'1raFFEitJ17JG�:. -1�:.1V:kkY;�i; ,'..7v7.L '`.r.',S'•?q 1'^:i:�i'$rilmsi�l1+.eity1�.tyv 2l�i$1F �
Well Contractor Name YY • FROM TO DESCRIPTION
. -2•.� Q ft. 100 (� p �:
ft. t
NC Well Contractor Certification Number
75 rittio.olsThrE�'f` doifitt a s2a*..nyto>ilit[Elti(ifap iteatfe K F X,ti,.�,'„+:i,;
(i(u l P. ® W Y ,p L., Fzu-. l To 1 ni mornR 1 THICKNESS t MATERIAL
ft 1 c r ft. .i iirll in. ( cA 84
tympany Name en (• 7 7 v
/ �'��. G�®�q 4 \ fi i lGa1INNER(1,e.filDtii�`.F3i1t�TiF$INfi'fi eiflNei i',rI"1 1nse i:ulil� ', *4.4':'�'s�'i's
2.Well Construction Permit#: (� t FROM TO ' ' DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),State,Variance,etc.) ft, ft, 1 in.
•
3.Well Use(check well use): ft. ft. la.
Water Supply Well: � i t z0s' Lea. ;,Z4s':;r .: .t '1,4 �y, t r,.r fT�
`tCd1Bi�1!F R.rT.9 ,v y /.,i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural uaicipallPablic ft. ft:• . 4n
r,n__:L _1 nr__.:.._in__c_,.n.««&.5 .:w:.i....Mnl tSIntM Q.,««f..!:«..7..5......-. aI�::::. .... ."
\ C a��rrY/ - '�-•• �'.:Ci'i i-'- 'I� 11. I ll I I ri
-- - .__ —_ ..rry\... .:/ ";-,1$` `lr tU'U.�:'2..'fa.W :Y;ir' .d',,<,'>5-.War,"in.' YF`..f",4.v;•ten;,.� n'sC e`s"� f 3
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
t'Non-Water Supply Well: ® ft. 2.0 et. ala inn i g rtc �i
❑Monitoring ❑Recovery ft, ft.
Infection Well: ft..•
❑Aquifer Recharge DGroundwater Remediation
19 SAD/GAVE:TITA (if )Ucbie r b > - M 4sz '" -�'u
❑A in�ferStora a and Recovery ❑Salimt Barrier FROM } TO MATERIAL IEDPLACEMENT METHOD
❑Geothermal(Closed Loop) ❑TracerVYyV VVuuV+ ir.osoo an OG':(atioes bddiiii s'hYet if`ecless `.?'- ' at%;;A a z.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Hardness,sod/rock type,grain size,etc.)
0 ft. ft c'1 kl
4.Date Well(s)Completed:f al 1 .)3 Well1D# gj 0 ft. 1a® ft. ;1'a C ( 4.k
Sa.Well Location: '`i Ht.. [^,r^Q,--n w�.,, ,,,.,y �ft.: ft i 1 't�--L., t5�i tins/Ta5Oh NI �,on 7 r
Facility/Owner Name FacilityID#(ifatrnlieahiel 1. � 'I it. i,- F Eli 2 2ov
r t
7 3 55 Pt,h elta r fr.!i h
Physical Address,City,and Zip P � / ft. ft.
.
br.tiiis1,,r •ii;1 M ; ,1 l' Unit
DiAritg�A2Pi14F�`.?�.x ub�t-.error `u,,.�'^i�3:'�\ 4.s_'�:�.a ,a;. y,f msTa;�+r',i<
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one ladlong is sufficient) 22. A/tine:Itlon:
6.Is(are)the well(s): EZiPermanent or ❑Temporary • Si��s' of Certified a Contractor bate
13,Ksigning this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Iti1Vo 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fi11 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 detail:: •
S.For Geoprobe/DPT or Closed-Loop Geothermal.Wells having the same 'You may use the back of this page to provide additional well construction info
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.
dril`e.: ! i 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: ® (ft.) Submit this GW-1 within 30 days of well completion per the following:p
For multiple wells list all depths if d(fferent(example-3(0200'and 2®100') 1
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Pro'llssing Unit,1617 MSC,Raleigh,NC 27699-16I7
If water level is above casing,use"+" - 1
11..Borehole diameter 6 (in.) 1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,.1636 MSC,Raleigh,NC 27699-1636 -
12.Welt cattstruetinn.melted:. air 9 o p/ n A tt f n f n ... «w n'n. ... iho ..
tie.auger,rotary,cable,threat punt,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) �� pp Method of test: IDi Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: k+h Amount: 77 • .6
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018