GW1--01284_Well Construction - GW1_20240229

--WELL.CONSTRUCTION RECORD-(GW-1) l For Internal Use Only: ' ' -
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Well Contractor Name FROM TO DESCRIPTION
4 ft. foo ft.
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NC Well Contractor Certificat'on Number.
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Company Name �� $). ��.. . 1 �. j'-
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2.Well Construction Permit#: FROM. TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,Countyv,State,Variance,etc.) ft. ft. i In.
3.Well Use(check well use): ft. ft. ! in,
Water Supply Well: 7i?SCRaisr„vm. :, , s::'`3N.z,„M„u,:.yR.M u z t cft*M ,,;aig r
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❑A FROM TO DIAMETER SLOT SIZE THICKNESS [MATERIAL
t °Municipal/Public ft, ft. in..
OGeoterm 1(Heating/Cooling Supply) OResidentialWater Supply(single) ' ft, J ft. 1 dn.
Olndustrial/Commercial ❑Residential Water Supply(shared) —_ 1 + I
. FROM T- `O
❑Irrigation ❑Wells>100,000 GPD MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: �y n, )0 ft'
ra d fl,
❑Monitoring ❑Recovery {� ft. ft. V f
Injection Well:
n' ft.❑ ifer Recharge ❑Groundwater Reinediation❑Aquifer Storage and Recovery OSalinily Barrier '.x-SAPPW77 A'U ;;'A (it appUchble7 '�_<• ., „ . ". �._iRi 3-,:Viz,:.
FROM I TO 1..MATEai i. 1:EMPLACEMENT METHOD
: i❑Aquifer Test DStormwater Drainage _ ft i ft. '` 1 •
°Experimental Technology °Subsidence Control - _a - tr. , i.
❑Geothermal(Closed Loop) • °Tracer i10tsiP71OG(uttiacTt'difatilouhl'sTle (Sifioail3iy7r :t."x�Pk�'. r= v
°Geothermal(Beating/Cooling Re ❑Other(explain under#21 Remarks) FROM TO DESCRIPIT0 (color,hardness,soil/rock type,grain size,etc.)
0 ft. ®0 f. 3 4 pA
4.Date Well(s)Completed: 45 214 Well ID# 40 ft. 2,0 it l ID
5a.Well
•
Location: sr„,1,1 gl.
ft. ft.
I
Facility/Owner Name , +J*..n9
�l{t Facility ID#(if applicable) • H' 1t ` fi.f
a! is/ 1t ° ft.
CEe 2 2 232
Ph I Address.C' ,and Zip it it. L 3t
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Y ±. w cuse a�a mrtjifcc•
County Parcel Identification No,(PIN) DWC11300
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
6 wcii uciu,uuc iaviutiy to Simi:nt),
'22:Certification:
.. N .... NV —ail..fa Kd -, '"H• 4; tt
r
jvV' Pt— Iles
6.Is(are)the well(s): pPermanent or °Temporary Si nue ofCertified" e0 Con Date
_/ By signing this form,!hereby certi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I5iio 1SA 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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
9.F^:..r. ^'=terrzwr nr^In-,,a T.n-n -ri+?int..nt.i•ar..n,,,,,..:.,,:..t....,..,.,, You may use the back of this nage to.provide additional well construction info
constriction,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:: _._ .,:.
0
9.Total well depth below land surface: 0 !
For multiple wells list all depths if different(example-3(a�2 'and 2©100') ( .) Submit this GW-1 within 30 days of well completion per the following:
i
10.Static water level below top of casing: 0-p ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"}., ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (9'14 (in,) 24b.For Injection Wells:Copy toIDWR,Underground Injection Control(IUC)..
�- a Prnaram;1616 MSC:.Raleigh;NC-27699-16.36
12.Well construction method: • a[r 101-d �.Y '
(i.e:Sneer.rotary.cable.direct nu�h.rtr.,) ,ddd 24c.For Water Supply and Open-Loop Geothermal Return Wells:Cony to the
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
P� , `,, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) `�1F"
, Method of test: '
13b.Disinfection type: i Amount: 1 l
Form OW-i North Carolina Department of Environmental Quality•Division of Water Resources Revised 6-6-2018