GW1--03132_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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FROM TO DESCRIPTION
Well Coon]tractorNainnee
YIN .
NC Well Contractor Certification Number 1. �pY�i �. h 1SLgUfiBR GAShIIYC lo!m Thera.. .
r� u
wills OR L�S�kER(,t�tf a "lic"ztile`*`r?�� �� s
` a 1 �Vlw � f FROM �. T DIA,IIETERIn. �x' V U , ATERLAL
.Company Name
2.Well Construction Permit#: FROM To DIAMETER I THICK .ss MATERIAI.
List all applicable well construction permits fl.e.VIC,Couno;State,Variance,etc.) it. ft in.
3.Well Use(check well use): it, ft. In,
'Ya':.Yti1 �`ruS�i; �'=''}.%<.v:� x ,�+•, yr'+ rs:_"�•2 s:y,.
Water Supply Well: � �...�;�. �--� ;-�•:,��,«��v.�c;�,-�s:.�i t �.r�=ash x �r. ;
pp y FROM TO DIAMETER SLOT SIZE I THICXNESS NIATERIAI,
❑Agricultural ❑ umcipal/Public ft., it. In.
❑Geothermal(Heating/Cooling Supply)' residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial []Residential Water Supply(shared)
131 i ation ❑Wells>100,000 GPD FROM TO ' MATERUL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. IL
❑Monitoring ❑Recovery It. ft.
Injection Well: it. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Bairier FROM I TO MATE I EMPLACEMENT METHOD
❑Aquifer Test 17Stormwater Drainage it" ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ^r1Oi?11f511<lG t£aElrxcP3itiJo5iiti"s}Ye'eisfnecess `. [ t a+ <,m;$e ;
❑ 01 n Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To nFscR>e S co r hardness aolUrock a rain st: etc.)
it. b
4.Date Well(s)Completed: "'�'3 Well ID# % 0 ft. 'A�
Sa.WellLocadon: p it. f 0 Tt. 4,o, �—
Facility/Owner Name Facility ID#(if applicable) ft, ft
o VrAL°V r ft az�t� ft. f ,.
Physical Address,City,and Zip ft lilfiu,+r 1 f` i�t r d
�L 1 � •Y/ 1 ` l �O v�3f`� ��i'Siri,G'CI...ti@�'...'�i��)v4:kr�4.�asJ:�•'r•'ul{+.�'�a.,.x�a�'IoZ��rt..,�: �� n:at^�,�.�.UYC'�'""�'
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
N W
6.Is(are)the well(s): 4permanent or ❑Temporary Signatunfof Certified Well Contractor) Date
1/ By signing thisform,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or 40 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this 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:
VV4 Wr•. �,.w�I,n karU of tl,:a nano+n nrmririn adrtitinnal 1vr11 rpnctnirrnnir'Si'D
S.'For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: L 24.SUBMITTAL INSTRUCTIONS
.9.Total well depth below land surface: -3 d O (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dffer•ent(example-3Q200'and 2Q100')
10.Static water level below top of casing: �0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater•level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
'11.gnrehole diameter.- fin.)' •.�. "In n nn r w
�-/, Program, 16J6 iv1JC,i�ni8igty 11t,c rU77-mv ru
12.Well construction method: air l o�k�� 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: r 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
�b W Permit Program,1611 MSC,Raleigh,•NC 27699-1611
13a.Yield(gpm) 5 II Method of test
I :
13b.Disinfection type: n�� Amolirit: Z
r nn r.W.1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018