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HomeMy WebLinkAboutGW1--03163_Well Construction - GW1_20230505 WELL CONSTRUCTION RECORD(GW-I) For IntemaI Use Only: 1.Well Contractor Information: ta5o11 P061k, Well Contractor Name `FROM .w TO DESCRIPTIONw ° d1-)1 rt. Sd rG 3& h^ 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• ,r/'•/J yu . w. 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 p 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