GW1--06315_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: : '
1.Well Contractor Information:
Zo ih. P00 k in*V..4.1VVICAES
Well Contractor Name
FROM TO -
Q-).1 ) ,8 ft. tic) ft. DESCRIPTION "'
ft . (9VI —
NC Well Con trot Certification NumberI. In pD:TEW;G 1&IIDIGAbirhluliW sedrwells)OIt 1NBR•(tril'livable) ,;
Ci r� c 1,, \� �� 1 ?,..,,,,,,ir FROM TO r-DL1M TER , THICKNESS MATERIALsCompany Name iii""" 9 it. (t ft. 1" m. Ca
16 TNNE0f.ck I1�T.G:Dl rttBING"eotherml closest loa y2 u'0 „
2.Well Construction Permit#:1;A{t1tl !Mali 2-0 it FROM TO DIAMETER THICKNESS , TERIAL
List all applicable well construction permits(Le UIC,County,State,Variance,etc.) ft. ft { ' in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 33. CREBN a.,;. ` ,: G. •-. .,> ;'.: ..". _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 0 unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) - esidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) ft ft. in.
❑hri at10II 1$:GROUT..xt�. ::��:3v°K,'�4 _✓..� �-Y rWs:,ti;�'7';Shi„,,Gr '`u.. :: '..s�: -
g ❑Wells>100,000 GPD FROM TO ,MATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. -2.,0 ft. Iv ilF raut
❑Monitoring ❑Recovery ft. ft. ct
Injection Well: t tia
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation '
❑Aquifer Storage and Recovery ❑Salini $artier :19 SAprolGIi 1;Y�El,�,t'A (il`appltcabfe�., ? -u . �-y-9! -rs
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft rt.
❑Experimental Technology ❑Subsidence Control ft. ft. :
❑Geothermal(Closed Loop) ❑Tracer ,2tl'.<bBYttANG LOG(aftacitaddttlo'nxl sheets;if-'rtecessbyy)' ' ,.:y- ,t 4- ..,i ;.,"
❑Geothermal(Heating/Coolin Re rn) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soll/rack type,Crain size,etc.)
4.Date Well(s)Completed:1 2 24 Well Mt ft. _P5 it ��C.II
(IAA 415
a.Well Location:' ft !�t^® !t lo� g� � v oyc
el zic-
ft. ft.
Facility/Owner Name Facility
d1—,gFacility ID#(if applicable) ft. ft. sl.. ,`34Di Y,/�/`l�h ft. ft. n. . ^y, ,
Physical Address,City,and Zip ft. ft. 1 2024
��gq
i� e/ 0 /15 74 f C'Li, e,..41,R1-"1vaRx$!'. m.; ..: i,r.',';...:... z'.rt.an�'� 'l�'i- ' .., ' '
County Parcel Identification No.(PIN) 1± r- �' ,5 h
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Ce tification: Q
N W al')i 1 z a d/
6.IS are the wells: Y a Sip a of Certified Well Co Date
Is(are) () Rie m nent 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 LIIo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known 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:
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: 2_6 0 (ft.)
For multiple wellriist ail depths tfdii ferent(example-3@200'and 2(4)100� Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing:
(ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ri 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,etc.) couhty 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) d Method of test:
f
[a U Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: i to
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018