GW1-2023-02980_Well Construction - GW1_20230425

WELL UUINSTRUCTYON RECORD(GW 1
.) For Internal Use Only: '
1.Well Contractor I formation:
1!tysWA.TEI2;�DiVES. .:,r h Well Contractor Name FROM TO DESCRIPTION,.,..
�. I A ft. p ft.
ft
NC Wrll C:nntrarrnr(',erfifiratinn Nnmher ft
CP• b �L LI FROIf TO DIAMETER THICXNES3 ALITERLII _.
Company Name ft. ft. In,
2.Well Construction Permit#: 1 a r�Q` a q r1 `iR EASTItf©;b1l;TlfB 1 :"colheriria7 closed la o ..:..:. G
FROM TO DIAMETER
List all applicable well construction permits(tie,UI ,Couno� State,Var'r re,-etc.) ft. ft. THICKNESS MATERIAL
a-D �„� in.
3.Well Use(check well use): ft. in
Water Supply Well: .n;
FROM TO 7 ..;.w;r:rl do n„lr„ 1 I-IUidnnirinalkRrhlin DIAMETER SLOT SIZE THICXNESS MATERLAL
0G6othermal (Heating/Cooling Supply) r f '� taWater
Supply(single)
❑IndustriaUCommercial ft ft
❑Residential Water Supply(shared)
❑lrrl ation ❑Wells>
100 000 GPD FROM To � MATE
Non-Water Supply Well: EMPLACEMENT METHOD&kMOUNT
❑Monitoring ❑Recovery ft ft• e.K h e r et V'l
Injection Well: ft• ft.
❑AquiferRecharge ❑GroundwaterRemediation ft ft.
PAT e^_`1 Rnnnvun` MCOl;„;f,)r20TTIPP + -r ��il ' i �i�G'-�1('':,1{:•.liC r2 r i,,..o,;,s '.. '+
'�i annw.r
❑Aquifer Test - - ------- cnsot• o,icn,m,ecr,rnn
❑Stormwater Drainage ft. --
❑Experimental Technology ❑Subsidence Control ft.
it.
❑Geothermal(Closed Loop) ❑Tracer _2D;?ltiir.TTNG;Y;p;G.attacli'adihtiouatBh�efs"-iiiecesaa"" = � ?s_:❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM To DESCRIPTION color hardnes solVrock rains etc)
I a
4.Date Well ft s)Completed: ' Well ID# 0 ( p ft. d ft.
4 �•
Sa.Well Location: yt ft ft.
1t� �htt,Lj. ��if°�''� u ob .,r. ram e-- b <
Facility/Owner Nam- --a —� C + '•.,,..
Facility ID#Of applicable) ft. ft.
� 1(?1 n• ft. APR 2 5
Physical Address,City,and Zip ft ft
11n 1
— 702
� `G v`a
County Parcel Identification No.(PIN)
56.T.atihrde and Inn aitnde in dev_rep-Ominutec/seennds or decimal decrees:
(if well field;one iadiongis smiicieni)
24.Certification:
N W
/ "ZZ%(A ' is`7-z-
6.Is(are)the weIl(s): Permanent or ❑Temporary Signature of�errified Well Co tractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to as existing well: ❑Yes or 0 1SA NCAC 02C.0100 or 1SA NCAC 01C•0200 Well Construction Standards and that a copy
Ythis 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•
er. 23.Site diagram or additional well details:
�e�t rebels;i er v[ese^a ..:.nF6...., ; .,.::� �'�;;-c;'-rc 11- bwv.'::
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER ofwells (
1 add'See Oder in Remazks Box).You may also attach additional pages£necessary..
drilled:
9.Total well depth below land surface: 6 24.SUBMITTAL INSTRUCTIONS_ (it.)
For multiple wells list all depths if different(example-3(a)200'and 2®1007 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: O 24a. For All Wells: Original form to Division of Water Resources (DWR),
f water level is above casing,use ,+,, Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:^ �P
(in.) 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: ct (it 1r
(Le.auger,rotary,cable,direct push,etc.) 24c:For Water Su I and O en-Loo Geothermal Return Wells:Copy to the
county environmental health department of the county wherein stalled
FOR WATER SUPPLY WELLS ONLY:
�y ( 24d.For Water Wells producina over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) d'Sl^ Method of test• � 1'b W+- Petmtt Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1'1 T '` Amount:• _(_(n
Form GW4 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018