GW1--04468_Well Construction - GW1_20240730

WELL LOINS 1KUL1ULM KGL.111O (lrrW-1) ' For internal Use Only:
1.Well Contractor Information:,7 ,50A PoOIc 1 i rtief+Y�»Ypffaa1�� .ff } l '.,4 ll a�} .. Sa 5 ;V� ,s'
Well Contractor Name FROM ft. OO O ft. �� ON ,-
a�g ( A ft 3P .
NC Well Contractor Certification Number
p "oE t Cftor r l f' �i< FFt . tir
af Uc9 Poole- Well t [ tit[►Ar ( .6• FtipM Ttl lils VtFTrFR THttKNRC M,ITRRIAI.
Companyft.
ft.
Name /
1 > I in lxtyl.,
2.Well Construction Permit#: FROM TO
w DIAMETER TIUCKNESS 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. in.
Water Supply Well: :,,r:, r. ,e r.,.:_ ;Y: �,, *";i .>:.1:
'r FROM , TO ,DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agncultural unrcrpal/Public
ft. ft in
..-...« tT....._.._o 247.vi ..ct . .--o-i lb 1 I le ( 1}
DIndustrial/Commercial °Residential Water Supply(shared) 4:-. i!3f ` . d , �-,• r `: 3t £ c xt ; a` � '„
°Irrigation ❑Wells>100,000 GPD , FROM TO MATERIAL t EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ZO ft' be nth)i1L i r4 V
❑Monitoring °Recovery ft. ft.
Injection Well: it ft.
°Aquifer Recharge °Groundwater Remediation ---- ---�
s 19:-S,A.PID/GRAVEL'PACIQ(If applicable) _ k
°Aquifer Storage and Recovery °Salinity Barrier FROM ( TO MATERIAL I EMPLACEMENT METHOD
°Experimental Technology ❑Subsidence Control ft. I ft. .
❑Geothermal(Closed Loop) ❑Tracer 1* 'i tfdid#'sireeIlliC esaarsl C s'A N.,,r: at*,
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness wWroek type gale du etc)
0 ft. 10 ft' CiJq
4.Date Well(s)Completed:t II f 2123 Well ID# K 0 it. i o it. Suit. or,*
h ft.
5a.Well Location: '
T 5®h 'flv maso fl ft. ft: I _ ;-- - • f y
Facility/Owner Name Facility Facility ID#(if applicable)
ft. ft. : ..... a. ... + l...4„,„,73' J Po aryls l h , PI/
t,Aa \)011,1% it. ft. JUL 3 0 702
Physical Address,City,and Zip ft ft 1 1 .ill r
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. tification: 11
N R' -! /2 j t 21 25
Si of Certified We Contractor [D rate
6.Is(are)the well(s): Permanent or °Temporary
igning this form,I hereby cert fy that the wel(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 114 ISA NCAC 02C.0100 or I SA 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#2I 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 nrr�+pry.
drilled: ' ( 1 , 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` o (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3@100'and 1Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: e) (ft) Information Pro sing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 611 (in.)i 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
/� y Program,1636 MSC,Raleigh,NC 27 699•nt36
12.Welt construction method:. 0 /�(r 1 0 T(V(
(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
Method of test: P
tow
k+ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1
13b.Disinfection type: r1 Amount: ' f 2. (a�
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018