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=�
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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