GW1-2023-01556_Well Construction - GW1_20230209

WELL CONSTR1UCI'ION RECORD (GW-11 For Internal Use Only:
'I t
1.Well Contractor Information:
�0 Poo
' FROM TO I DESCRIPTION'
Well Contractor Name
NC Well Connector Certi catian�Number 1 1 to l ;r5k01321[t CSII�( (toGtii'u]if�aEd 5ellg�0iEA` 'biillca6fd '1:"=it1%> si'a
R Fdtemr lu ;3�
' L;1"a tvrernAML
ft �j
Company Name �^r► P 4'/� a� 1h1Z,
` 1 V #33 < b'I .d ll a .:s;." �;�`)a�,:r
2.Well Construction Permit#: FROM To DIAMETER THICKMS I MATERIAL
List all applicable well construction permits 0.e.UIC,County,State,Yar(rl�u'e,•etc) ft In.
3.Well Use(check well use): ft ft. iw
Water.$upply Well: yu, /V,��+ a_^ yz.atik� a;; ;,M. . .;-4 •'f., r i,Y, k .
�'.•�CI. V1lCI LK•.'•'.54''i C h��i:.1.i�' v1,s. 'Jl.%vT•�.e wti�.. U'fy��};�,r.i:i.. k'4 t�Y�i:?.':+.F:�'F.•i'.
FROM TO I DIAMETER 1 IISLOTSUM I THICYNES6 I MATERIAL
❑Agricultural ❑)llunicipal/Public fr, J ft.
ur,feotllermaf(iieaungluooling,apply) p Kesldenual water supply(single) ft fT in.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
0Y i,'a
,- ��. •..� T2'Siti•.�S.le`;,. ..t+'„ :.ia<Fa s- .1!}s.. ��'r'� ..-it v
❑Irrl ation . ❑Wells>100,000 GPD FROM TO MATERIAL AEMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: fr. 7-6P ft h
❑Monitoring ❑Recovery ft. ft
Injection Well:
❑Aquifer Recharge OGroundwaterRemediation fL ft
❑A uiferStora eandRecov DSalini Barrier '195" IGI2APAtL. '"'"lic4tilc• "^;fry %r'uti
q $ mY tY FROM.._ ..___TO• -- MATERIAL.- .. FrAK ACI..... T METHOD
OAqu f�r"list ❑Stormwater Drainage e ��• 4 a.
OExperimental Technology ❑Subsidence Control it
❑Geothermal(Closed Loop) ❑Tracer ta2o:ti3RIiiL1l+TGI:F ' 't#acli ati3itliin" tieersaec <=?'.FM+: r-r a b"
OGeothermai eatin Coolin Return ❑Other(explain under 021 Remarks) FROM TO DESCRIPTION Lcolor,hardness,sowrock type,grain An,etc.)
0 ft. It. A.
4,Date Well(s)Completed: �� 5 -�-�- Well ID# 7 0 n• �(�Q ft' 1 rivi�tie, r@ft. IL LJ
5a.n ell Lotion: A A ✓ 11
a _r«
FED I
FactGty/0 Name Facility ID#(tf applicable) H' R
n fr.
r/ r o—. .r.3 ..rt
Physical A eesss,■wC�ity,_annnd Ziip�►p
Y l 1`� 1- 1 • "`.ti;.'^`s:,T";;ra;'F7 '.."�,s-y�r`.'.op'�. ' ��'%'• -' r y_:y'�,�.•z;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(Ifuc ......... ..........
N W (� - 5-.L'L
6.Is(are)the well(s)t Lermanent or OTemporary Signaturethi,
ertified Well Connector Date
By si_ form,l hereby cerfify that the well(s)was(were)conshucted in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consh•uction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well.owner.
repair under#21 remarl r section or on the back of this farm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
constntetion,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells�y ;auu UGV V Yw Ill TW WfLLnil LVA1.,vu way om„at%m lr auuuiuuai ya�ca ii
drilled. ' 24.SUBMITTAL INSTRUCTIONS
9.To
depth belowland surface: (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@100)
d"b (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
I0.Static water level below top of casing:
10lfwer level is above casing,use"+„ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11_,Borehole diameter: (in.)
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
,t ptqiaram 1616 MCf'. Ralt!ieh NC'�7(,99.1(Tq(T
12.Well construction method.: �1`� 1 b���Y 24c.For Water Su 1 and upen-Loov Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health epartment of Ne county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100,000 GPD: Copy to DWR,CCPCUA
<,13a.Yield(gpm) Method of test: b`0 W Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: ,1T Amount:
Form UW-1 North lamina uenamnent of imviromnental uuehry-mvision of Water Resources Revised 6.5 701S1