GW1--04467_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
3li SO h 1-or o b`?.. T4,vV Tga zortts ;. - '`_
FROM TO DESCRIPTION
Well Contractor Name ft `CO
jw fl g fno
79 pr ft. (j ft.
NC Well Contractor Certification Number 15;OUTER CASING(ffor�-a ulti-cased:wells)OR LINER:(Ifap 11csblej ,4.;;;
Cq rn P6o i c- �a rut r c_4. FROM TO DIAME1Eifit in. THICKNESS MATER>
N p p ' V,.., ... ._.
Company Name / 1 ;.:; : i.
�j C.'
'.Itk-1NItIER Ch t":'Oltr:`1'_1JBllV. (g J eYtneCelu�sed-loiapl' ,. .
2.Well Construction Permit#: CFO R✓a6- 0 I v I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
17.:.SCREl b c.
'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS ^ MATERIAL
❑Agricultural ❑ icipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft, in. ~
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:I3RQi)T ' i
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHO &AMOUNT
Non-Water Supply Well: b ft. 71, rt. l(vr fiii Ifav(=
❑Recove t
❑Monitoring ry ft. f
Injection Well: —
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND1GIEA BVP.ACK`01.apPlicfitile) .
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer .20.DRIELINGi ?(Atticb additional sheets if necessary)';'"
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) �y/�
/ �f C ft. cc ft. c izt
4.Date Well(s)Completed/4 I Z Well ID# 6 o ft. /go ft S ',{tt r)c-k
ft. ft.
5a.Well Location: r.. •, "
beta k i I O d ft. ft. : ., J
Facility/Owner Name ' Facility ID#(if applicable) ft
ft. J U L 3 U 2024
I $.c Spcnct r). ft. ft.
it ft r ;1744:::::',C!; 41:: ,';',41RIVP-f.
Physsicall Adddares,,Ci ,and ZipffRE lr t., r�
14-1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 22.Certification:
N W 0 11 -;--Z3
6.Is(are)the well(s): L�Permanent or ❑Temporary Sign crt' ed eW ►1 Contractor Date'#-X--
By si g this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well ❑Yes or o 1 SA 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:
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.
drilled: I
J� 24.SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: ! "0 ff (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 2Qa l00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 70 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Cf
/' (in.) .� Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: L( I/ 057 r A
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,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
l+ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 40 Method of test: 1'46
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{(iJ
13b.Disinfection type: Y i 1 t e Amount: Ai/;tom l y
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018