GW1-2023-01557_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: i
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1.Well Contractor Information: i I
�q (/� ;r1.,���c� •ern
�C erb PI`.� •�1�hZlYs'!���.u1h' vN.'7'• wy�'.e �c:`3 ri'•�1~'±%'� ,`. �:i':•' %:7:4�%:f^ro rd: ;f �r:•`ir«:
FROM TO DESCRIPTION I
Well ConVictorN ne iG ft.
�pa fG ft. i
14Y',,ati Glf 4VllifCt:iV["4ctu+lyquv i•'iiauiu�, '
�a�;;OtFT1riz:CiAB �:fotiititilfi:`edsed:�i�lis:i�• R: as�.1(eaBl'e'';: �t=1::��'�y�:�:
lr� $ FROM tt, T0, DIAMETERIn. THI MATERIAL
.• VC,
CompaayNalne .�y� /F� ��y�a ,��y},�r�y�e `r •�
7FL� '4 �O1illT.."1V;i Vl7RLl� et�i��OS��Jti 'rf•15.i:`.'�rtky�f Zt'.+4L�^��S+J��I.
2.Well Construction Permit#: FROM To DIAMETER THICKNEI {- MATERIAL
List all applicable well construction permits(Ze.UIC,County;State Variance,etc.) ft. /,V ft. in.
3.Well Use(check well use): n. ft. in
Water Supply ram;-;:4 `" ,-,yv
PP Y Well: FROM To nllki _Sl.orsizE CKNEss MATERIAL,
ur►gtit iiituisi i iiv uuisr7pl]1)Yab114 % ft, ru- I
❑Geothermal(HeatinglCooling Supply) idential Water Supply(single) ft it. !a
[ Industrial/Commercial ❑Residential Water Supply share
E��i;. t)�t' �'.v.=.-.cue... .)�fi':a•:�ir:-3v''-'' .� .'iysrr•'.�i- .�.�..-.:�- x s•1:�.
Cllrri ation ❑Wells>100,000 GPD FROM TO . MATERIAL EMPIACEMENTAKHOD&AMOUNT
Non-Water Supply Well: rG ft Y Cv6 4
❑Monitoring ❑Recovery ft ft.
Iltfecdon Well: ft R.
❑Aquifer Recharge ❑Groundwater Renaediation
:'T9"!iL�k 'rf7t_Y_II�A'rf.R�,+lM:tir '.'.'•.th�',:t .i'?-.'t%,r �.t;�•ra�it:='��F.p;-ti'�~S',•:
❑Aquifer Storage and Recovery Cl.1•aunityliarrier BROM —To:' MATERIAL E*LACMLM N'cMSTsiOn -�
❑Aquifer Test ❑Stormwater Drainage ft tL
❑Experimental Technology ❑Subsidence Control iG ft.
❑Geothermal(Closed Loop) ❑Tracer ;> isyT - trat tfon td' ii ece"" _I'a 'ins4 u=• >a'r
13Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,aardn ;off/rack n dze at41
fr. ft. G a
..,4 Date WeIl(s)Completed: -12- Wellm# fG ft. 6V
'; s'"�'isr_n• _��� G•.(�sll'" (_A/fA..Il�- f"''. T'.•r-t��--,, _
Faeility/Owner Name Facility (i£applirable) fr' ft.
b
I C GJtiy h. mac, fG .
l..i:�
Physical Addren, ity,and Zip
naavv e:� of t t7�a r t
�w e,/ g� e��,w,�fG� R. 1'3lo-t. �.rc.•o �
! ��Y`I`S 'O .'�.i.::�itran `f:�i:F'i+?+,cti.''F,"iii''iF#�7ri• T.w"Pt.: -.t3,v:',: pvt3i h�,J.'J3.•5' f y'+;r'^•''a�= .:k.'.:::?'iri.
' County Parcel Identification No.(PIN)
gyp:Liantuae aau iongimue rn-uegrcz.wLuututc4ra (;vuu5 Ur-uct:aimaiL ugga"-3;
(ifwetl field,one lat/long is sufficient) 22.Certification: �•/ q
j 6.Is(are)the well(s): ❑Permanent or ❑Temporary Si tune o citified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were) oastructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 34 1SA NCAC 02C,0100 or iSA NCAC 01C.0200 WellConstrui Ion Standards and that a copy
Ifthls 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 ofthisform. 21.Rita diagram car 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 additi t a1 well construction into
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach a itional pages ifnecessary.
dulled: ! 24.SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: W® (ft.)
For multiple wells list all depths ifdVerent(example-3Q200'and 2@100) Submit this GW 1 within 30 days of well completio per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft)
Information Processing Unit,1617 MSC,Raleigh,NC 7699-1617
ifwater level is above casing,use 1
?Qh.,Fnr lniantinn wpnQ.rnma In TIUM: TTnrtr•rm m d TniAntinn rnntm1 MYr.)
ct.tsureiauia tiieructCr: v'+w lYr�l Program,1636 MSC,Raleigh,NC 27699-1636 Y
12,WeIl construction method: r�+a V
2. er ror construction
direct method:
ere. 24c.For Water Supply and en-Log Geothermal eturri Wells:Copy to the
( > a arya a P ) county environmental epartmart o the county, ere installed
1 FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over,100.000 GPD Copy to DWR,CCPCUA
(�13e.Yield(gpm) Method of test: PennI Program,1611 MSC,Raleigh,NC 27699-1611
� c� � ;
13b.Disinfection type: v` Amount: s,
17 r r.W_1 Nnrfh rarntina T)mnnmmt nfRnvimnmmtn1 0—th -ruvicinn of Wnte RrAmimoc 1 1 Revised 6.6-2018