GW1--06339_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-il For Internal Use Only:
1.Well Contractor Info ation: �} ,�. j •
7� n b o ef , .
�i 4.`TATIOU.I �rO f`#a'k1 Ssy^r,i?g z}L't'_a..3 per... ,Wig1•Y,' fig2".?yf✓M;%?e"ss'T=t
Well Contractor Name FROM TO DESCRIPTION
a-IS I A ft 200 ft !S J J ,n .t.-
NC Well Contractor Certification Number ///��{ '�S"?[k' tit{A6II16(;o:i luld=c'sed ilj'iTGO It:�tlf`n °licslil'el-A u y>4 A=`s
�'" "Ar / _ FROM TO DIAME E THICKNESS MATERIAL
C�r�d P 61eRili 1 +lJ)'�i7P • t ci 1
Company Name ft. 1Q f0 in r j 5, �C
'l �y =T&,Yi?P'-,ASIIMOttIOVNakaiithaiiiii tlatiff i bliakASZ Vc'-�4:YI:. k RTC
2.Well Construction Permit#: COt i I ed g 4051 30 FROM TO 2? DIAMETER THICIGo ss MATERIAL
List all applicable well construction permits{.e.UC,Countyv,State,Variance,etc.) ft ft i In.
3.Well Use(check well use): ft it, i' in.
Water Supply Well: =r!%F IM nr..'., :; ...X 1 ki' ?:: ,.. „"N x,;zed• „,,�, ;ash:,:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural ❑ unicipal/Public ft. ft. In.
°Geothermal(Hearing/Cooling Supply) lkesidential Water Supply(single) ft, ft, in,
❑Industrial/Commercial °Residential Water Supply(shared) h.`•a thin ft,i,t r _ ,4 `.4. �.0; r Y,af,^. ,'r,,,-"V` .2
❑Irrigation °Wells>100,000 GPD FROM TO - MATERIAL EMPLACEM METHOD&AMOUNT
Non-Water Supply Well: 0 it 1-0 ft iY)Q1 111''6j array,
❑Monitoring °Recovery ft. ft. I ' J ,_y ' ed
Injection Well: ft. ft I 1
❑Aquifer Recharge ❑Groundwater Remediation I .�
4lr'011Z.G,R1V'•S iI,"�Ir'.AL , blfpilr:lii/14W,,n..,��A li.2g :..rvagilli,s.
s
L ;&
DAquifer•Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test OStornrwater Drainage ft ft. e
°Experimental Technology OSubsidence Control ft. ft. .
❑Geothermal(Closed Loop) ❑Tracer : ifalsilGXt7 attail.. ii'dtttoiia fet$,a a ssµ £.�`�,. ,Oe
+ , � �IKyB 9�IC I�neees$il�y�.� ��h °S j`€x
°Geothermal(Heating/Cooling e ) ❑Other(explain under#21 Remarks) FROM TO DESCAIPII�jN(color,herdne"solVrock type,grain size,etc.)
C� I ,( 0 ft. o f. sGt(i!A
4.Date Well(s)Completed: I o� "1 WellID# (+0 ft. 1 b0 ft' S(i v1 of cp►rt '
5a.Well Location: /o oft -c 0 ft j a i1 IT c f OC 14
Ttxe. a ftk ft. ft :
7,.n� T,., t
tY u)' (ifapplicable)
ft. ft ¢ `L Z.-.-'ti,'ii.::a V L,�...s]
Pacility/OwnerName i -it
Y 1 Facility ID# a licable
3o Sa*"e r cull-i rd+✓ /43 tat S'(11I16 cg-75'f( ft. ft. 011 9, %071
Physical Address,City,and Zip pi ' ft ft'
Fro vi i`I ill ®®(06® F i 1:1tomfI ;M.e?n u f r a t+jxnr ,,o3•aa--y'ego;`sr! „`cw�+,,,,-; �.i1n aF
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W A, ?eiste.,4-2 i.8t A Jo -I (0-011-1
6.Is(are)the well(s): ilaPermanent or ❑Temporary Si..�pure of Certified Well Coma 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 tlo 1SA 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 an 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. 23.5ite 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]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: _ . tO 80 (ft) 1
For multiple we list all depths ifdifferent(example-3Qa 200'and r V2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: D, (ft) 24a. For All Wells: Original:form to Division of Water Resources (DWR),
If water level is above casing use"+" t information PrOtoesing Unit,16i7 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (�,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
�i- Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: CI I r&1 0(7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the•
(ie.auger,rotary,cable,direct push,etc.) 111 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) ! Method of test: b (6 lid Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: in' Pi Amount:_41I b
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018