GW1--01467_Well Construction - GW1_20240301

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
15®n PePb1ed ila4 ikl?ER OA'ES`:�<- ,�bt N' ;I}M. __ . �,., yj4._., Jx.£,?,
Well Contractor Name FROM TO DESCRIPTION
ft. 16,6, ft P01
��� ft.. . ft. 1
NC Well Contractor Certification Number 1,
9 faS�OU OimTEWCASINGulti cased iie11§);ORT MIliifa licable)x r ?` „A
G1 U ,0\y Po' b k. ' �e I (; ls (/' lllJJJR p FROM TO DIAMETER THICKNESS MATERIAL f@ �` " In ft JA.r ft. ,®' Ily a in f nti' 1�g n
wu,pauy i`,OLL/Ci '9 a `*,=• i r e. 1 0 9 ^C IY riI.t"C(tt((1
��v "Xcf
t 16.SINNER CASIrTG:OR TsUBII�: (g tti"er.'iiieltcleseii`lgop}r r'r,,.^;.,;rS rt' ":F..-.5.
2.Well Construction Permit#: Qy' ��m 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. • in.
Water Supply Well: 1Z1SCREEI\i '...s'--y .,.-s r:.:-, t a ::r;li,w:-- _'ili ra.,, :tzcc`, .�.-,
i FROM TO DIAMETER SLOT SIZE, THICKNESS MATERIAL
❑Agricultural ❑ icipal/Public ft. ft. 1,1
I
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.. I in.
EI1"__a... _.. ... �^tIitiOROt1TosM r,.V::.. 0 EWP ::..;..,.': ..
❑Irrigation • ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a® ft ._. �i rTc u il
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. it.
❑Aquifer Recharge 0 Groundwater Remediation I
t
❑A uifer Storage and RecoveryOSalinityBarrier FROM. .D7GRpOT1Y GKa(M T Re ible. ,,,£, -.::_, ..__ - ti METHOD
q g . FROM TO �.MATERIAL 'EMPLACEAIFrNT17ETHOD "
❑Aquifer Test ❑Stormwater Drainage ft ft.
OGeothermal(Closed Loop) OTracer 2b!'rl?ATLT ItitG O0(a rich dTtiionat,slieeet53t-nece`s's`ary}-',if mw' t..;g
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM �lTO DESCRIPTION(color,hardness,solUrock type,grain she,etc.)
�+ n-� a ft. e, it d
4.Date Well(s)Completed: I! — 7-l"I Well ID# /o f 7 0 i 0 ft. p p ft. e 1+,0 1..®c4c.
5a.Well Location: $.,c j( Cot it... :yl, ' _
Ce0 1 5*f -J .'it. !' ft. R�+ka izi V C.
Y
Facility/Own Name Paniltty Mil Ofaynlirahlvl ft. It. _ •,
9xoS Rci(deep*n d(r. iliac .( � ft. ft.
Physical Address,City,and Zip I ft. ft. iilft7i Yati!_%-°n?rr ow.a 1Si{
///p\k' `y1 2ia12IYrsRXCS;c ?:.t's .',,,_.w ,,.. x s..3,._.>' x . .a" i:.-
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient). 22.Certification:
I; r: • I a 1 Ili
6.Is(are)the well(s): Permanent or ❑Temporary SigneI f of Certified Well Contractor I Date
By signing this form,'hereby certify that:the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15,1 NCAC 02C.0100 or 15,4 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:
8.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.
drIll"tl' II i1 24:SUBMITTAL INSTRUCTIONS
9.Total well depth below Land surface: V 0 (ft.) Submit this GW-1 within 30 days;of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
10.Static water level below top of casing: —CP
(ft.) 24a. For All Wells: Original foim to Division of Water Resources (DWR),
If water level is above casing,use.,+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copyjto DWR,Underground Injection Control(IUC)
11_Borehole diameter: (in.) Program,1"636 MSC;Raleigh,NC 27699-1636
12.Well construction method: Ct9 r ('OTarY 24r.Far Water Snnnly and Onen-T•onn Geothermal Return Wells:Copy to the'
ti.e.auger,rotary,came,auect push,etc.) y 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) i-e Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
�� 1
., 13b.Disinfection type: -A ' Amount: AI 110
Form GW:-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20.1S