GW1--01461_Well Construction - GW1_20240301

vv JLIt,L kAJ.LIt lli.0 1.::1:11JN RECORD (GW 1) I'For-Internal Use Only: .
1.Well Contractor Tnfnrmattrm-
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i'"RW2f ly7,740.S•;L.i ��3+'c :o3?'ft>-.atil4,,, 1 C'✓, �5k..� _* �' i�e�Y:
Well Contractor Name FROM TO DESCRIPTION T 5` rr
�7 L� ft. 3 S 0 ft, 3 q pi)°6i1 ft. rt. I J i
NC Well Contractor Certification Number
61,141 Well
1.. .1`);R t�BT1YQ=(oz<lnul#i casid`'.vellsj;(iR'k, R(,rap l... , i
Nolo— is E- G .FROM .To. DIAME`TIER THICKNESS. 'MATERLII:
p tiVPcp, rt. 1 it in. �[
Company Name tr ©/ el e du `vi (Tt
Y V ✓�' ", u;-44g. w:rurt etosea-Aaopt..,a '`{$r�:7 ... �.2.Well Construction Permit#: r FROM4W TO 5w DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Count;State,Variance,etc.) ft. ft. i, in.
3.Well Use(check well use): ft. ft. j, in.
Water Supply Well: ':7,45CEtiE$k': ;*^,: £ 'nor Ow,. :ZYMKYa:t:. nx =•'g: .. 3 a 64-741 f
❑A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑r unicipal/Public ft. ft. 1 III.
❑Geothermal(Heating/Cooling Supply) I(dResidential Water Supply(single)
ft ft. I to
❑Industrial/Commercial ❑Residential Water Supply(shared) f R /r{iderwsz: '
t-e= u'VVn11S 1UV;VUVUri, FROM TO MATERIAL ' EMPLACEMENT'- TROD&AMOUNT~
D
Non-Water Supply Well: 1 it
0 ft. kr p rt , j rz v i❑Monitoring ❑Recovery ft. ft.
Infection Well:
DAquifer Recharge ft. ft
4u g ❑Groundwater Remediation
DAquifer Storage and Recovery ❑Salini Barrier 19`0` 1,0 SPA (l alspficablE ._. -M ,.;PF (
ty -= FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStotmwater Drainage ft ft
❑Experimental Technology °Subsidence Control ft ft. ,. kk
...u.aaunr ....rvacii i.uui.i) UTracer ' _.i.If;llki 'r... r(a't,E8clt3aditt'allal' OE$llr'A6e2$$
�,�.�- 8r5`) SAWWa.c,,n�'I t l..,s..:1n>:.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FE tal TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
J !� 0 ft. 1D ft. GIf c
4.Date Well(s)Completed: i 1 d�''t'�q Well ID# ft 'e% ft. 5 f k e.
5a.Well Location: 50 itLop .. !rr.vi 1l-e-- - � `'
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RtkRj = .is ft ft i Vhtii�✓tk ,,E)
Facility/Ownerme Facility ID# ifa applicable) ft ft.
tY ( PP )
5137 .0 -tl r°",.„a -1 .. _ MAN fl 202'4
,j 1 liit4 L4.C.G1\ 1(f. I '"
Physical Address,City, d Zip ft. I ft. i �t i�� 7r r
0(�Y f, el zei 3 5 D5� .,.mil. '�3;'i.t # Y1`5., 2ti �,..is:��•s .,Y }.�*AY�t .kv tx 1 3:,.
County t, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifieatio •ys N W 1, 9 ^...1.a�jZ)l _ '
6.IS(are)the well(s): [Permanent or OTemporary
Si( ture of Certified Well Contractor ,y date w v
By signing this form,Thereby cert(that]
the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o ISA NCAC 02C.0100.or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out blown 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. I
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells baying the same 'You may use theback oT"this ptige to provide additional welhconstruction info
.construction,-only 1-GW-1 is needed. Indicate TOTAL NUMBER of-wells (add See_Over'in Retnarks-Box).You may also attach additional pages-if necessary.
u
drilled: I c 24..SUBMITTAL INSTRUCTItiNR
9.Total well depth below land surface: 4 )Qd
For multiple wells list all depths if different(example-3Qa 200Eandd 2@100� (f(ft.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (XV (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: (j (in,) 24b.For Infection Wells:Copy}to,DWR,Underground Injection Control(IUC)_
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 'fr rD r 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(':e.auger,rotary,cable,direct push,etc.), county environmental health rienaitment ofth,nran ry when.=nctoned
FOR WATER SUPPLY WELLS ONLY: 1
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
n t if Permit Program,1611 MSC,Raleigh';NC 27699-1611
13a.Yield(gpm) .) . Method of test: (v via
13b.Disinfection type: 11 4'L Amount:, 1 1 Lb
1
I
Form OW:1 North Carolina Department ofEnviromnental Quality-Division of Water Resource` .Revised 6-6-2018