GW1-2022-10701_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD(aW-1) For Internal Use Only:
1.Well Contractor Information:
DA up') .
FROM TO DESCRIPTION
Well Contractor Name —•
//�� R. ft.
3-�r)3 ✓ ' ft. ft.
NC Woll Contractor Certification Number
'i•15;®UTER11
CAS G ror'riulheased''�wclls'CDR'T.IPICR rF&"'I:celLlc ��%•
G Q e ;�) ` . FROM TO m`1410.ER THICKNESS MATERIAL
C,r G+ / fi Y _ ft. ft. in.
Company Name
' -16'7>yN6R:CA5ING OR.TUIIING "nthcirtndl:clBsed lne � •
2.Well Construction Permit#; FROM TOI DIAMETER I THICKNESS - MATERIAL
List all applicable well construction permits rI.e.UIC,County,State,Parlance•etc.) ft, f4 in.
I Well Use(check well use): ft ft. in.
Water Supply Well: t9:SCft1;EIS,>a":: . ,,
FROM I TO I DIAMETER SLOTSIZE` THICKNESS I MATF.RIAI .+
❑Agricultural ❑Municipal/Public .55.11 ft, 1,aig,11 ft 6r in. ®1® (f® �_-
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Ira ation ❑Wells>100,000 GPD FROM TO Y MATERIAL EMPLACEMENT METHOD&Ali70Ul'r
Non-Water Supply Well: .
— _ - ' onit0ring- - —-. t7Recovcry Ie --—rt—— — -- - --
Injection wen:
R. R
[]Aquifer Recharge ❑Groundwater•Remediation
19s'9ANID/GR1CV1 I PALY£` ,a cattle N' ,,7,:!_' r
❑Aquifer Stomgc and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METIIOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control. -ft. ft.
❑Geothermal(Closed Loop) []Tracer ;20i;11R1li1ING L`Odr'ntfai li addl ounitttieets'af necbssar :1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM -ft. To IL DESCRIPTION color hardness solDrnch type, rain aim,etc.::
4.7Date Well(s)Completed:l0"(0^Z� Wen IDll,5M{1,AP—/®IP ft, fC
Sa.Well Location: V 1 a L)
Facilit/OwnerNamc ft. ft. t_ t. L
Y Facility IDlJ(if applicable)
mz�DC
r'ek K O A J wl C.-
Physical Address,City,and Zip A 18®8 C ft ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/ininutes/seconds or decimal.degrees:
(ifwoll field,one lat/long is sufficient) 22.Certification: .
6.Is(are)the wcll(s): 1'ermanent or ❑Temporary Signaturo of Cerified Well Conuacto: Date
By signing this frrm,/hereby certfy that the well(s)ivas(were)constructed bi accordmnca is'vh
7.Is tide a repair to an existing well: ❑Yes or P o l5d NC4C 02C 0100 or•15A NCAC 02C.0200 Well Construction Standards and that a cr ay
Ifthis is.a repair,fill out known well constniction hffbrmation and explain the nature of the - ofthis record ha.been provided to the well owner.
repair under#21 remarks section or on the back ofthis form: 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use_he back of this page to provide additional well construction info
constmction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary,
drilled: ry 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:I A 5 (ft.) Submit this GW-1 within 30 days of well completion Per the following:
For muhiple wells list all depths if dffierent(example-3@200'and 2@100)
10.Static water level below lop of casing-. (fL) 24a. For All Wells:.Original form to Division of Water Resources (DWI),
If water level is above casting,use"+" Information Prac.6sing Unit,.1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b,For Inicction Wells:Copy to DWR,Undergmuud Injection Control(IU4:)-
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:- - p®A,7 C24c.For Water Supply and OpeA-Loon Geothermal Return Wells:-Copy to fbc
(i.e.auger,rotary,cable,direct push,eta) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: f
} - 24d.For Water Wells producini:over 100,000 GPD:Copy to DWR,CCPCUn t
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.-Disinfection type: Amount:
Fomi GW-1 North Carolina Department ofEnvironinental Quality-Division of Water Resources Revised 6-6-201N