GW1--06317_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: I
1.Well Contractor Information:
gr.-.d0� ®O f4i 1?I!A'I':.E12;-'2;OlVES �:�.�?`��"'�Y;?� ,7�,:-u„�rx ,�s".;::...r' .:,t::(�'"ur4:�,�.:� ��f.��
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
a l l ft. ft. I 14
.
NC Well Contractor CertificationNumbcr .s.; x E
18„OU'1`ER�Ci9i91WG([ortiiul#t-caked�te11s��OR L71!tEIt{ifap'ltca6fe) . .._. :,.s.
Weil r. �w ,�q� FRO/S�T TO DIAMETER THICKNESS MATEyRpLIL
��� P66 ,2- UL� �. Y' Y.It. ft. 8� In VC `
Company Name ,16 IN1�il;R�G BINf:.I(IIZ;tT:[1B11�1Fx,( thieiiiiiit iiii.a hill .Iki:t�-::>a>k ,h,;. 'k':f-
2.Well Construction Permit#: 6W " a 0,a/47'D-0 � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits a.e.UIC,CountyV,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft' ft. In.
.1?'l-: CR1?iO ziye OL VfrV'�'t ,.�. "fzzI�.. : .;f.Z)' 2a 7 .Y4�:.r . nr, :�k .M
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• ❑Agricultural unicipal/Public ft. ft. in.'
❑Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) f$$Gf20T1T o„4 m k�i µ t .Ta..n x .. ss.i , ,S,_«`-,_ .; Y-
❑Irrigation ❑Wells>100,000 GPD FROM TO MATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Ao ft. b❑Monitoring ❑Recovery b ft. ft. a Jr-MbI-II
njection Well: ft. ft. . JJJ���
❑Aquifer Recharge 0 Groundwater Remediation 19.. ND/G1 L.1AGIt(if sppIicab rle) sr:,�+4_3.);:s;;n .:, cti Oa' H O:' ?
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. ,
OGeothermal(Closed Loop) OTracer a10 bRIL'T.IlO?f'dtx(sttaeVi'ddltio'iahTshe.ifitt`naces aFy ',<:x r`` 'g .'r. .:.'; .
FROM TO DESCRIPTION(color,hardness,soNrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) �
❑Other(explain under#21 Remarks) �y fr. 1�ji it �i
d
4.Date Well(s)Completed: `'I 1 aq Well ID# .
0 ft. 10 ft. i I-0 Q A roe,
5a Well Locati n: q V ft. 0 0 ft. -rq n;- rock
Pp n
ft. ft. & _ • ,. LFacility/OwnerJ5ra�weI1
me Facility 1D#(if applicable)
s ao l tilsivr B Ike (n.•3VO Ce, a(0,s�l" ft. ft. U C T 2 2 2024
Physical Address,City,and Zip % I/ ft. ft. ii ., 7✓;:--
Q ' `�i aa4535 S� .Z-Fi,RNaM#iiits.,i z�.`._"'`'.:,..�t�.ts AYE:..;...," r ?:<!,g,F. <$a° �8. ,..-:4£',:
County Parcel Identification No,(PIN)
5b.Latitude and longitudein degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
i
N Wr x 'flJf6IA ).- 5— ii
6.Is(are)the well(s): Permanent or OTemporary
Signa2alJ1
of Certified Well Contractor Date
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 iiiNo 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: 00 (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(g100')
24a. For All Wells: Original foam to Division of Water Resources (DWR),
10.Static water level below top of casing: (fti) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,userr+'
11.Borehole diameter ID '4 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
,//�� i Program,1636 MSC,Raleigh,NC 27699-1636
vl 12.Well construction method: t r (titarl 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
�_( Permit Program,1611 MSC,Raleigh,NC 27699-1611
�
13a.Yield(gpm) 10 Method of test: ( V�
13b.Disinfection type: ilt h Amount: I: 1 [
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourdes Revised 6-6-2018