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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