GW1-2023-02938_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
(
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Well Contractor Name FROM TO DESCRIPTION
ft. 0.fG YY►
a-r 9 A ft. It.
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r�A B p i/�D I well
I FROM ft TO DIAMETER THICKNESS MATERIAL
(x r 1> p bS'ft In_,11 VC,
.Company Name ,.,...�... . -' < _•
2.Well Construction Permit#: W v > 3 EOM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl,e.UIC Counq,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. it. I in.
.yy: Rp-i"'"' i •?",ty,,4�r�ti"5 .ti:t.`.s+;v ';. "�"" 4'M ti' F
's!�{•t.'�.''�'''1�'�:.Ylc S�c`>'ttcuk�2�:t;.yf�:: =SZa;n::k:t�tu'c.�i?•ri?��;KpY "�`: " ..y$.'ss_'s7i*. .<>n�.t.ab'%Ku�.i'�'.
Water Supply Well: FROM I TO DL1i4IETER SLOT SIZE THICKNESS I MATERIAL
UAgricuitural u iunrcipa/roolic
❑Geothermal(Heating/Cooling Supply)' gResidential Water Supply(single) ft. ft. in.
❑Industrial/Commerciai ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO ,R MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' Z.0 ft be yliv Iq a V 1
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft. •
❑Aquifer Recharge ❑Groundwater Remediation
t��l4�Q"d.1'►'l(CI;!'c'4CP;T;P.�f?K:"'.Fil�.aiioti¢a lel�rs��.t:.,.:mat,"sr.#:a�.;:Lz�a'•.ts?�.,axik$::`
❑Aquifer Storage and Recovery oSalinfry hairier FROM TO MATERIAL I=mmPLACEIviENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ti��liIiSTis% acssdxTaftio�traili6efs fi neEe :: " : 1?G ; x
❑Geothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION c or hardness solUroek a°rain size etc.)
O ft Z ft. t9 P S 01
4.Date Well(s)Completed: — Z'� Well ID# a 1'. '60 ft. 4
! - i7 ft. 7D f. G/:r. C?t7UlQ
RQieb2 �A h Sd`4 c 0�1 l a� ft.' 0 0 ra_
Facility/Owner Name (( Facility ID#(if applicable) ft. ft. •d 10
�f aq 01A ���barn is • V'i �I�� &m1 I C ft. ft. APR 2 5'2n23
Physic6al�A�ddresss,,City,and Zip ft. ls
SZ�i.c '1ie%s•r.T�%=tiks*.'r'M._%y:f.� ;,r_.,;ft: :y ..,.4:" . N.
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesiminutestseconds or dmiina iiegrccs:
(ifwell field,one ladlong is sufficient) 22.Cer` 21
tion 2
N W
6.Is(are)the well(s): Vpermanent or ❑Tempora7NO
Si of Certifie we Ca etor Date
By rgning lhtsform,I hereby er•tio that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1SA IVCAC 02C,0100 or 13A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 of this form.
1.4.Cits+rlissaram nr arlditinnal well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional we11 consttueticnImfo
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: 24.SUBMITTAL INSTRUCTIONS
.9.Total well depth below land surface: `Z� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 100'and 2Qa 1001
op of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below t
10 St r• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
level is above casing,use op
��( .1;•....T..i-,.aL...Rlnllo. (',,..,.f�T1}uq TTnr4--^,in;Tmp.ntinn f'nntrol MJC)
11.Borehole diameter:, (4•) Program, 1636 MSC,Raleigh,NC 276994636
12.Well construction method: Lt 1 r !r o wV 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i,e.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) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27 99-1611
� � 011W
13b.Disinfection_type:, Amotirit:
Fonn OW-1 . North Carolina Department of Environlnental Quality-Division of Water Resources Revised 6-6.2018