GW1--03163_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD(GW-I) For IntemaI Use Only:
1.Well Contractor Information:
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Well Contractor Name `FROM .w
TO DESCRIPTIONw °
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NC Well Contractor Certificatio ft.
n Nin
;}`15,`.O�, • It'(:i45 , fo�'liiti iz�s' � :23R""- R�rfb• cable' x.x'�; :. :-�k
c ,-&k a Q, v - FROM TO DL1bfETER 'THICKNESS %ATERIAL O ft
Company Name �—"' to
2.Well Construction Permit#:_ ' FROM To
-- W17 THICKNESS MATERLIL List all applicable well construction permits r,e.UIC,County---,State,Yariirie etc.) _ ft. ft. !n,
3.Well Use(check well use):
Water Supply Well: lY:a�l�.'
❑Agricultural FROM TO DLt1rETER SLOT SIZE TMCXNM
❑Mu MATERiAI,nicipal/Public ft ft, an,r
OGeothermal(Heating/Cooling Supply) gResidential Water Supply(single)
ft. ft In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) .
❑iti ation ❑Walls>100 ilR
,000 GPD FROM " TO MATERLIL EMPLACEM Non-Water Supply Well: O g, 20 ft METHOD&AMOUNT
h e Gc
❑Mortitoting ❑Recovery ft ft.
Injection Well:
❑Aquifer Recharge El Groundwater Remediation fc
❑Aquifer Storage and Recovery f7Salinity Barrier' rfi 15NAl�RA 4. s L� w. ,yR
FROM TO MATERFAL Fri At
(]Aquifer Test ❑Stormwater Drainage ft ti EMed 1T METHOD
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer h0�.. 1' :i =addt rir3it13h fe t:rie : y
❑Geothermal(Heating/CooIin Return) ❑Other lain under 421 Remarks) FROM TO DESCRIPTION color herds son Ck f3rpn yze,etc,
ft. rt.
4.Date Well(s)Completed: �Ld {.' Well Ii g, R,
So.Well Lucat'lon:
�;v _71 MAY �
Facility/Owner Name Facility ID#(if applicable) $
ut-g'i3 f71Y1
Physical Address,City,'and Zip ft, tt•
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1 dl.��� 1� �r'i+�l�`` 2'�'r'.e�t`xA �.t.,.rci .1_��n:.�W;,.r.U.c••'sx,'a"•r#`�M.�''`43;.. ��rt4..''4`.�ti�•`�:�"::ti'w`.`..
county Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(iflYel r•••id,ona Ir.".aiia is eo—iCmi,
22.'Certification:W
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N �'� 1 �7 3
6.Is(are)the weD(s): E9Yermanent or ❑Temporary 5ignatun of Cad Well Contractor Date
__// by signing this form,l hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or API, l5A NCAC 02C.0100 or 1SA 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 thisjorm.
23.Site diagram or additional well details:
S.Far GmnrAhP/nPT of!'inc�A_r.n G^^tWl ar-rs_t__e__:A. Vrnt may,Y�e Lt:e w'vn^f Fit'"pagc
=r .,allar,_uto bauic +�yas�t�Nivviuc tiutliiionai w611 construction mfo
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: 1 24.SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: P V (ft)
For multiple wells list all depths if d�erent(example-3@200'and 2@100) Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing: ),6 (f�) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use
d+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: w (in,) v 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
prargrarn,16°i-6 iut"..,Rajoiaii,14C 27699-1636
12.Well construction method etc,) 1 �� tl'
(i.e.auger,rotary,cable,aired push, 24c,For Water Su 1 and Oven-Loon Geothermal Return Wells:Copy to the
county environmental heath department or me county where installed
FOR WATER SUPPLY WELLS ONLY: f 24d.For Water Wells roducin over 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) � Method of test• , W Pernut Program,161 MSC,Ra etgh,.NC 27699-1 11
��13b.Disinfection type: Amount: Z
Form OW-1 Noah Carolina Department ofEnvironmental Quality-Division of WaterResou ces
Revised6-6-20I8