GW1--06295_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .
Contractor Infor tion: L
1.Well i
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FROM TO DESCRIPTION
Well Contractor Name ft. o ft. 5 i.ern
NC Well Contractor Certification Number St.7-G rT1;RCt16Ilgfr(formuNt*cis'eta:ellOGR=1;IlYEK'(tf=ap Leabfr:)�•.,:'-^..A
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FROM TO LtW'
THICKNESS MATERIAL
j��( ®��tt, ���[ 0 ft. 1 7 ft. in II � /ompany Namel IIVG�:(£e'uitelmstelbsed>ltio'fi) �. .. i, :'.`-m f,
�P aq- ®n 0 0 3 4. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ee n• ft. In.
List all applicable well construction pennies(Le.UIC.County.State,Variance,etc.)
ft ft, 1 in.
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3.Well Use(check well use): !At BeRBEf a,,._'> .i:_giOgg .l s° :{?`Em,;aN .` -g,: i Est . s
Water Supply Well: FROM- TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑pIunicipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) s fResidential Water Supply(single) ft, ft. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) Ng.R O-t e.;, .° :. :.c` v.:Mft;4,:: • =`�.� "`��`. `� `"'�,~ `` " '
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL }l EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. .o ft 6i1-�f tlel j ragl i
:Monitoring ❑Recovery ft. ft.
!!! GC
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation4ce1NDJGI2At'FiLpi'<CK(1CaPpiicirble# =hb xE,: 34-= Mt
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❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OStormwater Drainage fL ft
❑Aquifer Testr
❑Experimental Technology OSubsidence Control ft. ft.
>.. iri.3t.:lw��YY �,t Yj�, l
OGeothermal(Closed Loop) ❑Tracer <2(tiltl G'. *att4'dliadattunafsli ets•tf.=itect ashy
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling R ` Other(explain under#21 Remarks) ,o ft"So
ft G
ft.
4.Date Well(sCompleted: 3 la 1 Weller 0* 1 %AJ� ft (So �� roG�
al
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5a.We Location: -eavex �eA= j550 ft AD/� it. YQh1TL 6 (®Gk
ft. ft. V
r "t _F( tt
flity/Own[ Nam o`/c�I ft.
e Facility ID#(if applicable) ft. e T
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Itii O Tttrigv wa 11ddIe.svx °1551 f. ft ,.:,a..�...';CZ. n.
I I ft. ft. T Q i /I17d
PhysiAca'l Addtgss,City,and Zip y( /y 2 �,y� � t.. � . .Y•aztt •.r'.�,, y:f;
Parcel Identification No.(PIN) ]t„o., .0 �:0.1
County !' V..v s.i:'1 t.%-Z
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.
(if well field,one lat/long is sufficient) 22.Cer s [cation:
N W % UGC * .D.D-564)A 3 lc,
(1.11
Sigma.' of Cettifie Well Contractor Date
6.Is(are)the well(s): 6aPermanent or ❑Temporary
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 itlo 15A NCAC 02C.0100 or 15A NCAC:02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out blown 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:
S.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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a.ei 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths((different(example-3Q200'and 2 a@100�
10.Static water level below top of casing: ' -C) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
(� 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �p (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: air ro+Q(Y 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13 l tO IAJ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) `,, Method of test: + I
13b.Disinfection type:
� 1V`* Amount:As 11' 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S