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GW1--06293_Well Construction - GW1_20241022
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I 1.Well Contractor l Information: //qq If r0 6 7el MAYA 1 r`..OA u,.i Rg l.:V .i,,ik.:"M rt i Y` .nt,'.r ,V4i. FROM TO DESCRIPTION Well Contractor Name ft. aqo tt' to 4 0 rn 1--/A AA I ft. ft. ' k. NC Well Contractor Certification Number `,sj OEIt i5IPIGIto> u1f1-egse Yielis);'©,I�'7+IPiER tftjj;;i'-12e itca6le)�'0 ° `p=� ,,p (` i FROM TO DL4Dr R O . i in. [THICKNESS o I Company Name� _�:. {r ,d d A A 1.1 A L� FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: i V V 19 1 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): ,#x;SCREELsT ,-^,,.? _ Mtg ? ` ' ; W', r..w:.��-:•s;.,., _r.Atc S;. Water Supply Well: FROM TO DIAMETER SLOT SIZE T ICIINESS MATERIAL ❑Agricultural ❑Iylunicipal/Public ft. ft' hi. ❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft in. ❑IndustriallCommercial ❑Residential Water Supply(shared) 18 �ROB� ���t '� ' v�> - ''}c 4 y r `¢ ' " . EMPLACEMENT METHOD nit r Non-Water Supply Well: O ❑Wells>100,000 GPD FROM TO ❑Irrigation f' ft MATERIALh t ra u -Wiled( e it ft. ❑Monitoring ❑Recovery Injection Well: ft ft ❑Aquifer Recharge. ❑Groundwater Remediation at rW1GRAVIEpAGI('(i(apphC 1JI)_ ;.r ;,..EVAM.k•9; `A .r`" j'"i"' ❑Salim Barrier FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Storage and Recovery tY ft, ft. ❑Aquifer Test ❑Stormwater Drainage ❑Subsidence Control ft. ft.❑Experimental Technology '3"? " ❑Tracer 21f'•.0111L1Iht+G=DOftstt4ch adartlohil slteetsif;nepesitfO _.,.. `M ❑Geothermal(Closed Loop) FROM TO DESCRIPTION(color,hardness,soiVroek type,grain size,etc.) . ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft' r]a it. &Joy 4.Date Well(s)Completed:314 n# ad.4 Well I O(1 5© ft• !r aQ ft• b r0 O c k i'J C,18k� 00 ft. ac10 ft. �,Q&It�Z (oOlL Sa.Well Location: ft, it, � ._ - Facility/Owne/Name Facility 1D#(if applicable) 9 -S II,, Ai otci ie 5( ft. ft. 0I T ?, b 2024 LlY F�� f ,�f `-`7 it. fc Phys�' al Address,City,and Zip O1 00670 ix 4:.. n ri ;<h r1 y arxx .h , tA f3,C s T,._„& 43 County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:. 22.Certification: (if well field,one ladlang is sufficient) N W ; 'taatiA s 1-11g'if Signatur o ertified Well Contractor ' Date 6.Is(are)the well(s): ®Permanent or ❑Temporary � By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or 11NVo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,fill out brown 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 iweil details: You may use the back of this page to provide additional well construction info 8 c For Geopron only 1 GW-1 Closed-Loop Indicate TOTAL NUMBERUs the samells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. constructign, 1 is needed. Indicate of wells chilled: r U 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: a-! 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@200'and 2 aC3100) , (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: t/ 0Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+' r 6 '�4 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC) 11.Borehole diameter: f�,.�j Program,1636 MSC,Raleigh,NC 27699-1636 a i `v D'"r7 24c.For Water Suppl and Olpen-Loop Geothermal Return Wells:Copy to the 12.Well construction method: l y (i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed FOR WATER SUPPLY WELLS ONLY: I `.' Pest ploWgrateram,61llMSC,Raleigh,loover N 27699-16P1D Copy to DWR,CCPCUA Method of test: b i ow 13a.Yield(gpm) ! ® 13b.Disinfection type: 144.it) Amount:_III Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018