GW1-2023-02936_Well Construction - GW1_20230425

yr.,ui,s.,‘..vi00xact/l,l1.tu1.14 ttEcutw (UW-1) For Internal Use Only:
1.Well Contractor Information: •
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Well Contractor Name FROM TO DESCRIPTION
.k�ci A ft / r�©ft. 4. 5
ft. r 80 ft.
NC WellContractor Certification umber
a �oo� e' e f1'5:01J' EZt Cr1'3I f aerri dit46 4174 10-60 IiINER{t€•ip lie li s;,. 4,..U i FROtii TO DL1l1ETERTHICIGVESS MATERIAL
n
.Company Name ft. 115 3 ft.: in. 1 �e I ,,(�
ll W ®� J q a {� �O.ONAtill OiASIIV;(?.:ORiR LFBl (geoi6eiTrlia1 clos`etl l`oorn .L` ,. Aarrk.. sr�'r...°ti-
2.Well Construction Permit#: 1 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,Count;State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ffir7;• GRErEN,MI�vNs s_,E`ti E „'"Kip?" -uc.:...i'ri.,t:F>'rn t ��a.Yn�.7`-smi.3'.
j firSS,
❑A cultura'1 FROM TO DIAMETER I SLOT SIZE THICKNESS ,MATERIAL❑��unidipal/Public ft, ft. In.-
❑Geothermal(Heating/Cooling Supply) 6aResidential Water Supply(single)
ft. R to
❑Industrial/Commercial ❑Residential Water Supply(shared)
'18gROfIM a -0 ,-t YA 21.04z 'Shfg, i r 11 .
"❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT�
Non-Water Supply Well: 0 ft. 2 m ft
per d i,yitrte
❑Monitoring ❑Recovery Y1 raj(�
ft. ft.
Injection Well: •❑Aquifer Recharge ❑Groundwater Remediation ft.
it. .
❑Aquifer Storage and Recovery ❑Salinity Barrier ` ` 1GO C?gilMt>aTERI`alitili i t �;, A ,�, ,, NT ME O .j
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage "it.- 'ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer "2b<IiR 0ICS;114G(attachcaddii b iai"s'fie is itnecessdr3 .:, w.K q0:C124Ms=.;
❑Geotht mial(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM. TO DESCRIPTION(color,hardness,soil/rack type,grain size,eta) .
rt. .75 ft, to,4
9)
4.Date Well(s)Completed: 3-19 3.`yell ID# I b t
75 ft. , 0 it. S a W„I)
Sa.Well Location: ft. Zoo it Wei
- •
5
R r .S g t 1 ft. . ft.
Facility/Owner Name Facility ID#•(if applicable) H• ft. i :ti ;•4 j t_, Th
� I a e'en'+ tea Di i. ft. ft. -14 Li
-
Physsiicca1ll Address,es City,and Zip (1 �7y�/G�) } 116 n yft, ft. a+- d
AI 4 I C �•' 0 Y V V V 6 1 / ,2r1..:W�+,iIQUI1X§ , ')�.c rx,&�ti.J .Y.n ti`lti�<E ,�tif7 O ...It .!t P;F�L p,,nt,`!ES#ti $f ur.:i
County Parcel Identification No.(PIN) utvixaoo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufificient) 22.Ce a' is
• N W
�,' , '- lri 6
6.Is(are)the well(s): ( ermanent or ❑Temporary to of Ce a Well Con eto Date
signing this form,I hereby c ri/fr that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or glo SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this 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 1121 remarks section or on the back of this form,
23.Site diagram or additional well details:
You may use the back of this page to additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal-Wells havingahe.seme
construction,only 1 GW-1 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: a 00 (ft.)
•
For multiple wells list all depths if different(example-3@200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: a it. 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1RY (in.) . 24b.For Injection Wells; Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: q I r r a t wry
(i.e.auger,rotary,cable,direct push,etc.) / 24c.For Water Supply and Open-Loop Geothermal Return Wells:.Copy to the
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) S Method of test: !6W Permit Program,1611 MSC,Raleigh,NC 27699-1611
11j I
13b.Disinfection type: h�y In Amount: .,6 1/
Fenn.GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018