GW1-2023-02982_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�d 6 r� W. VLjtYTT.12'`�itJVl
Well Con tractor Name FROM TO DESCRIPTION
A ft. 6 Gr,ft
. alp'
ft. V ft. Y
NQ Well Contractor Certification Number ..
FROM 'TO DIAMETER vTHICKNESS �YLMATERIAL
ft 3 ft. In
Company Name Ar
1 .s ., R:Gkk:Sl Fs:OR1[I$ Crt:"ctetheCmalclosdtl.la"'
2.Well Construction Permit#: U 6' FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Van'a%"e,etc.) ft. ft. in.
3.Well Use(check well use): y: ft. ft. in.
t�-'1.S.C�2EF,HT
Water Supply Well: FROM TO 1 DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Aarimilhiml ❑MunirinnMihlir ft_ I rY M -
❑Geothermal(HeatinglCooling Supply) Residential Water SDI n
PP1Y(single) ft. ft. in.
❑IndustriallCornmercial ❑Residential Water Supply(shared) g -.-A.<.R.
❑Irri ation• ❑Wells>100,000 GPD FROM I TO I MAT EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 iL It. e f '
❑Monitoring ❑Recovery fa ft. -g f 5 j�
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation R tt -r 49 Y s
SAlYb1l�RAiVD1 PACK fa h to t
❑,ginfer CterA—and RPcou— nRnlinity Rnrri P.r cbn R_ T_!1 11RATCbi i LT.fbi !•L^1 CVT IRL�TV
❑Aquifer Test ❑StormwaterDrainage ft. v W
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer r 2ti?t1TitL1:I1+7 a3tacli.addiaauat`sFieet li eceseiff`"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiVrock type,grain size,eta
ft. ft.
4.Date Well(s)Completed: - Well m# -A to ft, ft.
k& 1(6�K
ft. ft.
5a.Well Location:
L a
Facility/Owner Name Facility ID#(if applicable ft. ft. APR 25
ft. fL '
p
�e.0 o -� i�' �f U C t�9r0
Physical ddreK
and Zip ft. ft. f0>o t�D4I (jam
��County Parcel Identification No.(PIN)
54,Latitude,and inneitude in degrees/minutes/seconds or decimal decrees:
(ifwelt field,one lat/longissufficient) 2=Con.
NC,>
W 5
/� ryiigning
ature of Certified Well C ctor Date
6.Is(are)the weIl(s): SdPermanent or ❑Temporary
this form,I hereby certify'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IV/0 ISA NCAC 02C.0100 or 15A 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.
23.Site diagram or additional well details:
Yn^mry nr_the han art?is r:r- �r�_.iao aaaitionnl...gin w,JOr^^ :f0
For GacpraheiD. 3r vrDseu=.LOUp vecaher mal IT-ells ha imr-rue sage construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attachadditional pages i€necessary.
drilled: A� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y (ft') Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if dierem(example-3(a)200'and 2@100)
iD.Static water level below top of casing: 11® (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
v, 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
12.Well construction method: Qi r Y y as q1 24c.For Water Supplyand Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) eouhty 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) y Method of test:
13b.Disinfection type: -1 Amount: -►
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Advised 6 6 2018