GW1--06296_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '!
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1.Well Contractor Inf ation::
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To& Ob\M'_ s r 4 t 'X` e 5 . g § o- eisfe,'}; 33F y a�-rgov^.'ymalo.> RRE0
Well Contractor Name FROM TO DESCRIPTION -
2't I A f4 220ft. to grill
ft. ft. , -
NC WellContrac Certifi buN ag a AM ,m,o biomit Y' :. ,,
T 1 ii 8`(Ifap' aw4 iB]LS'�
_bo 7 1�� f FROM ,TO DIAMETER THICKNESS MATERIAL
Company Name a ft'
jotiL 1gin 41 d 6 +J C11vra1P Y }. lj('1r rt1'i$ al ftwri i owoig tioi.w-,..my;:,zo-tt a ,, `i
2.Well Construction Permit#: y -- 1 11a. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le UIC,County State,Varl �ic&a,eta) ft. ft. j, in
3.Well Use(cheek well use): it ft. in.
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Water Supply Well: )7i;6t tBgtf 9 MOP 'Ai rgitg 'GIs S�:::•e gItil :as t,- x
cr4 Y,:4:.�-.w�i-h:. ..Y::.�.�x v>i�at•,4�.'v-s�si
PROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. ft. in.1 '
❑Geothermal(Heating/Cooling Supply) idiResideatial Water Supply(single) g, n. In:
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❑Industrial/Commercial .❑Residential Water Supply(shared) s ;• ,� :,�. �. G
: .'r�Q�'•V�•�+'.+5++'�:�r;•1`'�F ���yi.����"�e'c-.`�;?i�'r`-`•`•'?��`iYia��4'�'��°� ass
❑Irrigation [Wells>100,000 GPD FRQPI TO MATERIAL TEMPLACEMI6iT METHOD&AMOUNT
Non-Water Supply Well: Vft' 2.0 ft. bet vt4-0 qpivicky Q
❑Monitoring ❑Recovery ft. ft.
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Injection Well: "}} G[{ -
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation iafii$ i0761ti rtli t @P+, lfrtib_ c V '. ;r t-.ft.Or .
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MARLMATERIAL' EMTLACEMENCMEHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology. ❑Subsidence Control it. ft.
❑Geothermal(Closed Loop) ❑Tracer '; 11 R itrift utYdnab1►`eddri a tlet)="K, i':i'if' ;` ',a "x;
❑Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM To DESCRIPTION feeler,herdneckaoivrock tyua�aln wise,etc.) •
4.Date Well(s)Completed: t 41 ^2q Well ID# t0t I 0 V! 6fo ft' L.6 ts
ft' ski*, rO c.
Sa.WellLocation: 64,41 a cm& t50 2 4,�)O o ft. ss .at 'e Gt_
Facility/ Name Facility ID#(if applicable) ft. ft. ^tl..y
140 13e4r Rta (r .i rc ittR ft. ft. o-.T trZ 4
Phyaical Address,City,and Zip ft. ft. Ir`;,:..z. .r-r.,.,,,rr .,t4Y.r.
A. f 'tpY�'..11 ti' -,+"'7,`9{reT.._i�'& a�-`�,,�xr•'�'1Nii.H A s i':w ��A^c;,¢.;.�A .r:r.,
.�iil�;�i�cr� d� :�r".yt,�'} :+i' �-c"±X�'i•,9Y'ii;.:,•i...�i�`u4R:.s:�
County Parcel Identification No.(PIN) II
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' '
(if well field,one lat/long is sufficient] 22.Certification:
N
W
15..• ; ....2
6.Is(are)the well(s): �1Yermanent or ❑Temporary Signature ertified Well Aii ','.
Contra a- Date
By signing this form,I hereby certjfy t at thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LQNo ISA NCAC 02C.0100 or ISA NCAC 02C.000 Well Construction Standards and that a copy
If this is a repair,1111 out known well construction Information and captain the nature of the of this record has been provided to the well fowner.
repair under#2I remarks section or on the back ofthis 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 thia page to provide additional well construction info, •
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER cif wells (add'See Over'in Remarks Box).You may also attach additional pages if Augury.
drilled: I 4 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (f t') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells!1st all depths q'd fferent(example-3Q200'and 2®100)
10.Static water level below top of casing: b (R) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(]water level is above easing,use"+" I!� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole-diameter: 7 1A (in.) d1 24b.For Injection Wells:Copy to DWR,WR,Underground Injection Control(IUC)
�{ Program, MSC,Raleigh,NC 27699-1636
12.Well construction method: r r' ! 24c.For Water Supply and OpenLLaop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) J 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
13a.Yield(gpm) A ef Method of test: k/ )O,^ Permit Program,1611 MSC,Raleigh,INC 27699-I611
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13b.Disinfection type: hi-h Amount: 1 11'