GW1--06303_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Info rnw
ation:
Job �qfj� f�. uvoi'4lutiiol ',` ?° r .ra t_ g ,x `•a .wa i..�Ao-rx.:F,-v. zn
U V ✓ FROM TO DESCRIPTION
Well Contractor Nam ft // ft
fft, * ft. j I r
NC Well Contractor Certifi ation umber ,ri5`OItM'Rli,i i51L1 (Comu`i4.�a5e?)�aYells�;pRUitter 8ii Lca61e)�,a „.v it"=*=
( FROM TO DIAMETER THICKNESS MATE y�� i
GIN(11 �)� \jj �� y__ " p R� 1._ ft. IIfie . 0 4� �.11/Qii1G ✓r.
Company Name 1t% Elt`O.ASING9DR.'E;Obi#€iith'ermatilosed�l'r3.ai) - . . ^r,';';:"`.�-v•
,} G FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: v� ®+ V tt JKN
fn ft. in.
List all applicable well construction permits(i.e.UIC,Count};State,Yariance,etc.)
ft. ft in. •
3.Well Use(check well use): ` , t ,,,
S:j$CIIEElf �_ ,U ' ti c>. a. xa_< '4.`
Water Supply Well: FROM TOT DIAMETEIL: i SLOT SIZE THICKNESS MATERIAL
❑Agricultural unicipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) tIResidential Water Supply(single) ft• ft. in
i.
❑Industrial/Commercial ❑Residential Water Supply(shared) �t CROUT.mA= a� h k : Mr• . A n . t a_ N M
❑Irrigation ❑Wels>100,000 GPD FROM TO M,yArT���E EMPLACEMENTMET OD AM
rn
Non-Water Supply Well: ft' `'P ft.
61Ja1 B 't' ► r o f '- il'e .
❑Monitoring ORecovery ft. ft. -
ut
Injection Well: ft ft. •
❑Aquifer Recharge ❑GroundwaterRemediation ,ry.a IGl,2AWBL,PIXegoCappTtr§bl"e) 6... .�W " Mr.= A 4 Y= i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test
❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft ft.
❑Geothermal(Closed Loop) OTracer ,20:lfalet N 'st OG(aitaMittatti6uakshi ets�ltneeessaiy)��r ,;F 721'"'x-�` 1 'r T}_:i
IFROM TO DES RPTION(color,hardness,solVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) '❑Other(explain under#21 Remarks) - b ft. ' 0 ft. D r
4.Date Well(s)Completed: 44 Well ID# U ft. ft. a 4
0 ft. /') rt• c je
5a.Well Location: 1
( ftQY�} / t oo ft. 1 'I ft•D f t• J F I rt; rocJ
Fact•ty/Owner Name Facility ID#(if applicable) it.
9�16.67
'' -'' ;
1 00 112.6(C COO 4 1 PI M IV ti 16501)
k
ft.
n ft. fft. 0t f 9 n
P ystcaal Addiess,City and Zip
k.
ii . ill
alativaI
•v.i 1
Parcel Identification No.
(PIN) •
r ''';'7-41.
County 1, �a,�: ±�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer cation:
N W - 1'Cr ��6/,4 3111 I f.i
Sign of Certified ell Contractor Da
6.Is(are)the well(s): Perman Permanent 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 o 15A NCAC 02C.0100 or ISA NCACO2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Mown well construction information and explain the nature of the of this record has been provided to the well owner.
I
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
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: . 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 160 (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©100)
10.Static water level below top of casing: IO 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: - (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 6k1 r i oTe.(7 24c.For Water Supply and O I en-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 SUPPL WELLS ONLY: 24d.For Water Wells produ,ing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
+y_ .l 11•
13b.Disinfection type: (('� Amount: ,.- '++- - ,
i
Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-2018