GW1--06290_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information: I
Vi \ \'r V txttYvATERIzolo _ r.�.'i!.C'nf:�.,..e, ,y't.,i,., Y f l .r�n-.� t,igl�r�s�:�A.,i�..j.,f xf..,.
FROM TO DESCRIPTION
Well Contractor Name ft. ft. hi
S111 rt. ' ° ft £ ;jf .
t
NC Well Contractor Certification Number •..., f k
e �I5;0>3>TERG'>;51NG(fuYmolh-cast?3we]lajUltIINER`(iFhp�ltcatile)x.,s;x„
br.�y NIL
`dmit 1 tAA FROM TO DL1,�I ER THICKNESS fMATRRJAL .
Company Name ( �.V•A9 0 ft.
t I3LI ft. / j� m . 1l g y ra1vdor
T ° 6. #.'ll.6INIVt=Rc1SIINNO..01tTITAIlIN (ggeeotbesmel'Aiiiidd;lda{t}n,., '` .-,; ,., i. ,.�;
2.Well Construction Permit#: E. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coueuy State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
agi
Water Supply Well: .17 SCREEIIF..r; .`.Y•., .iY.? .�,sr k �, ;.,.gi a...., r ..i r.-'3 0,a :«.>.....s ,r
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROYIT 4 {. r 4:x ..'.�: ,,� : ,r. .;::: . ; ,4
❑Irrigation ❑Wells>100,000 GPD FROM TO MATE r EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n• ft. b. 61 191T6 j rav,-14
❑Monitoring °Recovery ft ft. L 1 Injection Well:
ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation
191SANA/GRA=VELPACIC`(if'applicabre}.:.f..::, } .:rr.*4:. -_ -'i �4e:..;t}=�; e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer >;20 fl101:1A igtiaOG:(mttaclradditlonalslieetsdfnece"ssarsyF3 rc ip z mw:r ,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. ID ft. Ja
4.Date Well(s)Completed: 1 I Q"74 Wel1ID# ® ft /00 fa b few n rocg
5a.Well Location:
(a0 f`' 10 ft. (f yek
r ft. ft.
onai p.)14,
Facility/Owner Name Facility ID#(if applicable) ft. ft p ";� , _:. ti ', .1';':.','^ :l
t 0 T�t�'Kt u,J. td `es� ft. ft. OCT 2 2 2024
Physical Address,City,and Zip
A!l 4a 36131
U131 ..��..i�i"MAR .'..-�a1 r.3.;3..,:2w F'�'�tf.1t. .: ".:..a".va'�"' '�-t 1 ',�dia!'4�� "�a.:. �'Fs�i 4 .Lu..�.i:
�-11 Parcel IdentificatioonnNo.(PIN) �+' t.� i�
County{
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: i.
N W Pri.ei. 7 t° -2q
6.Is(are)the well(s): f31TPermanent or OTemporary Sigma of Certified Well Contractor Date
Or
By signing 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 No ISA 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
constructio ,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.
dulled: 1 �, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 J' (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 2Q100)
0 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•+' e i
11.Borehole diameter: t61,% (in.) 24b.For Infection Wells: Copy to,DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
r.
12.Well construction method: 't of fo�QI j 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: 1 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
f
l 1-1 I. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Ilir
13b.Disinfection type: k I-lei Amount: b Lo w q"
1
Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-2018