GW1-2023-01492_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: r �a�'yy+•`R y ����yD ,l My q1 } v
MI��� ��0�� 14�`,k�R1aTls•TtiZOt�ES':.,r"5)��V/t�G''r9':Y���\�F�!C1!g';G�f..�� Si:;�:•`�".G!}.. S'ia4� i `ac„� ��'.
FROM TO DESCRIPTION
Well Contractor Name ft. t) It. n)
ft.
Gig;c�tlT�x�_�Sinr:rr�Fm,ltha..Pcw.11?�..raw...flvFtRtffSLl+�r.lr.. .g
rs Y^ fs p r FROM TO DIAMETER THICKNESS ,MATERIAL
r �_ WI►4 V� Q ft ft. 1n. d ! lC�U 1�l
Company Name �1 I SIC(tT.l) rE. ,,::.insr'c adeit'ft. , `r> °' .
2.Well Construction Permit#: I�— ®0 1 LZ'q FROM To DIAMETER TIUCKNESs Mn'r1RIAI
List all applicable well construction permits(i.e.UIC.Counq;State, Variance,etc.) it• f4 in.
3.Well Use(check well use):
tf?1r.;fi�i2EF,19"r.ii'*a,�„w .. ... �i�. .. �,�; .,�... .�. »;�,;.:�•. ' . ' ^Y,.
Water Supply Well: FROM TO DL►,METER SLOT SIZE THICKNESS hIATERIAL
1 1,IAgn Cultum! LJl impaiFruw1G I It. I IL 1 lA.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) g ft. !n.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
❑1rri ytion ❑Wells>100,000 GPD FROM TO MATE EMPLACLIMENT METHOD do AIMOUNT
Non-Water Supply Well: n 't /
❑Monitoring ❑Recovery R R
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater RemediationIM
400'cr1iI51 a� : R IT
❑-".q.tfer Storage'^dPtnnyel, trtalinitvHamrr II ou aRTO1 u,rv,Pr„p.r I IIMTLAIENfYNTyrCTuOn �
❑Aquifer Test ❑Stormwater Drainage n- It
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer iYI EJG pttael aikaicrdnal sliteeid e'dexi ° "L
❑Geothermal(Hestia Coolin Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock rain size,etc.
4.Date Well Completed: Well ID# fL 'L - fjl�iNl
Facility/Owner Name V Facility M#(if applicable) fL n
X%1 PYuw016 n rASer-OLI 000 ft.
ft
Physical Address,City,an Zip
ft. fL J
County Parcel Identification No.(PIN)
5b.Lat'1b„de s„.3 lotto fvde in degreeahntnutegiseconds or Qec1_mal degTeev
(if well field,one lattlong is sufficient) 22.
6.Is(are)the well(s): ®Permanent or ❑Temporary Si a of Certified We Co ctor Date
1 signing this form,I hereby certify that the well(i)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (Il7No 13A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
Ifthis Is a repair,fill out known well construction infonnation 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 additionai well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion the followin
For multiple wells list all depths if different(example-3Q200'and 1@100� y p per g'
10.Static water level below top of casing: 2 fo (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"
/j 1.
am 2dh.r—it.4o rig,.w.n... ram,.,, nNam TT.,a..,..,.,.,,,t T.,;_,r;_r—t-i mirl
11.Borehole diameter: n., Program, l ti36 MSC,Raleigh,NC 27699-1636
12.Well construction method: �( r t�Q ar
24c,For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) Icounty environmental health department of the county where costa ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingover 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) n Method of test:
Permit Program,1611 SC,Raleigh,NC 27699-1 11
3
13b.Disinfection type: M_�h Amount: Z
-- F - _
Form OW-1 - North Carolina Department of Environmental Duality-Divisinn of waler R ean„m,.e R eviaed 6(-201 R