GW1--01469_Well Construction - GW1_20240301

WELL CU1VJ'i KU[;11U.1V KP.L UKU(li W-II Kor internal Use Only:
1.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION
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A , ft. [2.0 ft. pats e 3 p ni
fc ft-.NC Well Contractor ertification Number
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F°; t TO 1 HIAM TER 1 THICKNESS { MATRRJAL .
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2.Well Construction Permit#: L A3- 0 0 0 4 5C 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. i la •
Water Supply Well:
7t< QElja»+ •i� � r i} t r n=i�k••� rw fi a4 ..F ;
FROM TO DI..MET1 R SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. ft. !nJ
OrVy�___,..__t m__.:.__(n-_t:_•-cr-7--;.A .:A_.:..I llr.....�Q......1../..:..•-t..\ f i '�
❑Till ati ____ ._._. -rry :•- �� h1g�t"ir12S�TIT:..,ltst e$1 5;Q i� ?�r"N7°'t;i�.f1 isn`r�s.tl+"'{`a4;,#. t ?3 '.,'tiay hi �ri
g on ❑Wells>100,000 GPD FROM TO MATE rsT EMPLACEMEN METHiOD&11IouxT
Non-Water Supply Well: b rt. A.® ft DDf T(4 l(Q (�G(vt
OMoaitoring ❑Recovery n, ft.
Injection Well:
r Rs ft.
❑Aquifer Recharge DGroundwater Remediation.
fit'`L•9i,Si4NDI.GSANtra':tiCI4(If aPPfie le}.. ,.1:- 1 ..u,yO r r • - 0..: l i_
❑Aquifer Storage and Recovery DSalinity,Banier r.FROM TO . MATERIAL EMPLACEMENT METHOD
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❑Geothermal(Closed Loop) ❑Tracer x'-1ti 1ilt1P g+1O tiG'.(liiiirdi addit7&a ateecs-`f€•`xieccieii6,11 4K-110Ati ,,y^ .5
❑Geothermal(Heating/Coolin. Return s� ❑Other(explain under#21 Remarks) FROM TO DESCRIPTTOx(eater,hardness,salt/rock type arnln size,etc)
4.Date Well(s)Completed:IA II .3 Well ID# 1 Of 50 Q f4 b ft. �0 �'
5a.Well Location:
ft.' kL.. t1.� ��/ G
LI-1P IddP ft 1Y �,7 .t».r � ..,
� tpFacility/OwnerName Facility ID#(if anlie.ahlrl ( ft f- ,ft, i�.
C((I5 (sear gun 1h, ft. ft. fviAKu1CON
Physic Address,City,and Zip 1t ft
3 ": u ElsiA titair;:it tS\v h%. afrg-s ti.e-Ze- �y t'Prgo t tt a 1 -Y,F 4
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County Parcel Identification No.(PIN) .
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5b.Latitude and longitude in degreeslmrnuteslseconds or decimal degrees: F If
(ifweil field,one lilt/long is sufficient) 22.Certification:
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6.Is(are)the wells): lrmanent or ❑Temporary Si ay of Certified Well Contractor i Date
By signing this form!hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CC 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
!f this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this ions. I: 1
r 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
constructijon,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.
Wit'" , 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 6 4 0 (ft.) 1
For multiple wells list all depths((different(example-3@200'and 2®100) Submit this GV4-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ® fh) 24a. For All Welts: Original form to Division of Water Resources (DWR),
(
If water level is above eosin use"+" Information Pro*Sing Unit,1617rMSC,Raleigh,NC 27699-1617
11.;Boretrole diameter: . 6 (in.) 24b.For Injection Wells: Copy Ito DWR,_Underground Injection Control(IUC)
Program,I636 MSC,Raleigh,NCr27699-1636
1'H Wall ennetrnotinn mpthnd: .- _ Rx- r.__iv a._a __r... a cl. Y n z -- r D , Wntro•f .o.t�tbw
lie.auger,rotary,came,ounce push,etc.) U j i j C 9 sea T county environmental health department of the county where installed '+
FOR WATER SUPPLY WELLS ONLY: t 24d.For Water Wells producing over 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 5 ® Method of test: 1)10!!19 Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: l in Amount: .1 t
j 2_ I L • ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 61,6:2012
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