GW1-2023-02937_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: yy
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-ra— 12A ��:� n, i! ?' .?::!ra= t.. eys z•�: s 5°use:
WellConttactorNarne FROM TO DESCRIPTION
ft. Oft.
ft. ft. '
i•: a!F1S ,GlJ1rN`tt�ArFtQi;ottiitiiiti 89�rflYelS:()RMLI:ji' R:Ift`e lleabfr;*,q�3''.dK;,t ?'
Ica FROM TO DIAMETER THICKNESS— l�1ATERiAL
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P ft, 46 V ft. ( in. �/ Q �J
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Compai3yName 1i) 1'INNETC�e1SIlYG3RT1I111G'. ]zotiicYstcSse�=1� ?'a�' �ac "fa ,. 1
2.Well Construction Permit#: �� w P q a5 11 io�� FROM 0 DETER THICKNESS MATERIAL
List all applicable well construction permits fl,e.171C,County;State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): it. ft.
01rS�C
Water Supply Well: l FROM ..TO DIAMETER I SLOT SIZE I THICHNESS I MATERIAL
LJfigriCnlLUra1 IJ1V 1L'lpalllll[)LLC iL-,, .3[.' 'YIn
❑Geothermal(Heating/Cooling Supply) q4sidential Water Supply(single) ft, ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEa�fENT METHOD do AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. ft.
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation ,�,
7xtV1]10,R:it Fl°;E7?i'Eal fff i%iicfifii°Pi)c f: +. ,`1`�,,.ita''icuxG wawa:i'_�e.ut'r::L:xY''.�:r=t'�.•..1,.:
❑Aquifer Storage and Recovery 0.8alinity rlafifer FROM TO 11 MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage
OExperimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer at%It1{31`,TaI1+l: ' 'at'saclr-' 3mfd6%7UT" ;sY=
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION cola hardnces,soil/rackatyp rain six eta)
6 ft. ft. l,p f
4.Date Well Completed: J Well M# 3 ft. 0 ft 5!L n
K we tr Vivi P_ . ;b ft. _7 7 taft. e,& e o.�e
- d(.t�1�CrA dIt'il'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
t -17� ft. ft APH 5 1023
Physical Address,City and Zip ' f f t -r ^w ,.. t -{
o , rri.tl�Crr i r. .,.,wr l,r
ke l 7 3 3Q 1 S 2S� ,'.,•^:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/hunutes/seconds or decimai degrees:
(ifwell field,one"la[/long is suffioient) 22.Certification:
6.Is(are)the well(s): vermanent or ❑Temporary Si,tatur f Certified Wcfl Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 06o 1SA NCAC 02C,0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
7Z Rita riiaoram nr�rlrtiiinnal.o,n71 Aafairp�
B.ForGeoprobetDPT or-Closed-Loop-GeothermaI Wells having the same .You,may use the back of this page to provide additional well construction into
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 ii 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l -L (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if doer•ent(example-3@200'and 2@100)
10.Static water level below top of casing: ILO (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
L_r._..,T_a__a,__♦:r_n_. n___.._rsTm •r_�_____._�r_:_,..:,,_n,,..ti„f Rrrr'')
lI.Borehole diameter: 1 •) Program, 1636-MSC,Raleigh,NC 27699-1636 v +
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i,c,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells pr6ducing over 100,000 GPD: Copy to DWR,CCPCUA
!
13a.Yield(gpm) ` 5 Method of test: yy Permit Program,1611 MSC,Ra eigh,NC 27699-1611
13b.Disinfection type: Amorint:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018