GW1--06272_Well Construction - GW1_20241022

1.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
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FROM TO DESCRIPTION
Well ContractorName fL UQ ft
Q:)-1 et A ft. ft. ! .
NC Well Contractor Certification Number lg pt12iWASTPTi (fot triult<?uased i$elis)t)7R Mele(ifap ) '
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iFROM TO DIAMETER THICKNESS MATERIALbQ�� { vv�v W� PriAr i� Co. m ft ( )...1).. ft. I (Vgl in elqq a 44 4(tett
} ::NDIEkt C MIR4)0R tFTIBYN(1"(¢eothernnat cloosed idop)`,"'. . .:4 ='WY',, ,> ;
Company Name cv W 10 i 1 —"6 3
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. " in.List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) in
ft. ft.
3.Well Use(check well use): ti u 4 ,,'r'.:z a x'`; � `-`�'•'
,-17 SC1tEEk`X ,�.�;: "__.,*.ra,.�"�.F.rrYv _..s�•+ai:t... ,.
Water Supply Well: FROM TO DIAMETER , SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. ft in
tllResidential Water Supply(single) n• ft. in
❑Geothermal(Heating/Cooling Supply)❑IndustriallCommercial
❑Residential Water Supply(shared) 18M120'UT0,,,s `%;,ll,`x . x FA ,:,y E <;if,, t.�li l u ,';
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT ETHOD&AMOUNT
n
Non-W
ater Supply Well: 0 ft '' Co ft' 19erti I)t+e) 1 CaU�7
01.
OMonitoring ❑Recovery ft ft T I I P
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 10 A/ 0-001C(ii•applteabiep_ ',. n <•* a `:
❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ft. ft
❑Aquifer Test ❑Stormwater Drainage
❑Subsidence Control ft. ft.❑Experimental Technology ��- �, ��r f`i�f�';�, _,�.
❑Geothermal(Closed Loop) ❑Tracer 3o„IIBILI114 � OG(att ddinoiialt sheets ifnecesaaryl
FROM TO DESCRIPTION(color,hardness,soillrock type,Grain size,etc.)
OGeothermal(Heating/Cooling Rleturn) ❑Other(explain under#21 Remarks) 0ft ft. ert
4.Date Well(s)Completed: 3 f99 a ql
! 11-4
Well ID# l 0 it. a o ft• rc a AAStrvin ei
Sa.Well Location: ft ISO ft. �
(ii vi ife (oG)(
CT rQirId f ft•
ft. ft. _ _ _.
Facility/Owner Name Facility ID#(if applicable) T < R
` ft ft tt ,. 4rt'li,_:,e r' 4:,L
;�}-b a ro P�c,3 1�. I V a ke, Giehi'1 'XIS 11 ft. ft OCT T 2 i�74
Physical Address,City,and Zip sx 1 rti e wx I ,4 �} s 4.. :. u 2 4 n�.
VJ a iced I 1 1l e�® 1i1�Ics t ��.:.,_ .. ., .r
tt-ff:,. x 7 rr f,n .J..n
County Parcel Identification No.(PIN) t: si.;r'3i.=..
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:_. 22.Certification: 1
(if well field,one lat/long is sufficient) �
N w fall
te w-u+ A 3 6 ( 2l
Siena of Certified Contractor Date i
6.Is(are)the well(s): 15(Permanent or • ❑Temporary
By signing this form,Thereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or iti4o ISA NCAC 02C.0100 or 15A 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 thejwell owner.
I
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: ` U 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I a 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 a(7200'and 2®1007
10.Static water level below top of casing: a-o ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
( ) Information Processing Unit,161,7 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'+"
11.Borehole diameter: t/4 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: a24c.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 produciiLg over 100,000 GPD: Copy to DWR,CCPCUA
b` ' I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) d'� 11__ Method of test: uI^'
13b.Disinfection type: I* /\ Amount: ' l- `L
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018
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