GW1--06321_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
II
1.Well Contractor Infor anon: I '
JO h Ik le`pifIII
rid!V E ERiZONES sr .<< i f x ter t o s f i s tt r ti. J
FROM TO DESCRIPTION
1 A
Well Contractor Name ft.. 5 j ft ;� .
'l '
ft rt.
NC Well Con ctor Certification Number r ) -
15:OIi1RA51NGlfomulha5elrxellsjiORT�WER.(ifap lica6le -:
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P0A��� � g�' FROvi TO DL4l2ETER THICIG��(IEjS�S MaTER�Lg1L
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ft �r:B ft �' m. t it s 4 1 eL a t 8
Company Name F'1G.:IL!t1V1yR C�`i1S NGOA�TCIS eother«ma"l ila§ed-luopti. . 1. f i„h• .:...%r
2.Well Construction Permit#: Ll d 1 I kir r 2-0�11 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. P in.
ft ft. in
3.Well Use(check well use):
x7.SIGREEN W _ A . U IM '�'1,...,' y ei, ..&: , ,F..g -1 tic:w? ' I •;:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ly1unicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) ��.,/kesidential Water Supply(single) - ft _ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
1$!GRO`f13';w..:e,v,mZ r£ :t, 3 3x . . _-... .._
❑Irrigation ❑Wells>100,000 GPD FROM TO MATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 61 'J�6 ft. ft. )}, Vvi Itt9. ( ti
❑Monitoring ❑Recovery ft. ft. i j
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation z t y
r19:SAi`DIGIUVEV.O.KGiC' rtijipi cable) ... } [W _..;, : �.,-..!f W1�:_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft. i
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 00,3)1110S0101300(itiadadditlaid'Aidiatiliagigi'A4MS .M4c,g'Stsgi
FROM TO DESCRIPTI N(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ' b ft 50,iNt' i
4.Date Well(s)Completed: t- ! -1i Well II# j, 1? ft. 4300 ft. -� Alit, ro
' ft. ft. P,
5a.Well Locan:
pus
Facility/Owner,o,
c Name Facility ID#(if applicable) ft. ft. 2 Rp . F,!r1 3 1 0 r , &a9*i4tL rrL, 6,9.1) .9)1 ft. ft. rL.cu �Physicaal Address,City,and Zip Iy (7 ft. ft. T � ° L4
$y/A e, 1-7 ti.J:c f,6-7 rt�`+;REMA .4'S;ti ,f; -a.rkr-.te,,rb'vn.... t'?,w*,i,:,, tc` t r `'
a•
County C``Parcel Identification No.(PIN) '%,U r-"'1
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
N
W
6.Is(are)the well(s): permanent or ❑Temporary
Si a of Certified Well Contractor Date
By signing this form,'hereby cer•t161 that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o ISA 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: 7 0 0 (ft.)
For multiple wells list all depths if different(example-3Qa 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
r� 1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: /lr (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above easing,use"•1-"
11.Borehole diameter: It (in.) 24b.For Injection Wells: Copy to DWR,Underground•Injection Control(IUC)
1 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: m 0 to (iiOrJ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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
to CO A Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 Method of test: 1
13b.Disinfection type: Amount: 1 1:7-, '0 r
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018