GW1--03169_Well Construction - GW1_20230505

WELL,CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Conttractor Infy rxormation:VLO \ u 0�/ i... "rl .'A, {}s:. 'n a3.. .:7. .AI
.'k�.�'.."vS. r„F..., n.,h.v... .:+....,
a
Well CononhactorNagme FROM TO j DESCRIPTION:�� 1 fL t00 fG
fL tL
NC(W�tell Contractor Certi@cation(NumberS.rOTJTER. ``SIIYtr for ifitlt►-c�sd ;a?vILs CfR°'T 'R;tf a `lioa6le .
�-,�•�!e � �(( r,, g ®, �y a rp�{ -�6 FROM To DIAMETER THICKNESS *"YB.Etl�i.
�.H Vl V l V V Yd�
fL fL to L
Company Name
2.Well Construction Permit#: "i FROM TO DIAMETER In.
MATERIAL
List all applicable well construction permits f.e.UIC,County,State,Yae3�t2:e•etc) fL ft IA la KNES
3.Well Use(check well use): it. ft, in.
Water-,Supply Well: .1.T�'�?3
FROM To DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural OMunicpal/Public ft. iL
❑Geothermal(HeatingtCooling Supply) toXesidential'W ater supply Isingle) fL' fL` in. -
❑Industrial/Commercial ❑Residential Water Supply(shared) %1B.." Q
xh.i�`:.?C��:. ih<r.Lt'i.,..... 2,.).i,-',it.. ,•.r•*_..r, a.�.;4,;- is i.�?4:.
❑Itri anon. ❑Wells>100,000 GPD FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: (7 ft- 2 o n' 6 J (, r
❑Monitoring ❑Recovery fL ft.
Injection Well: fL % Y! y
❑Aquifer Recharge ❑GroundwaterRemediation ��
/.aicvli' �•i.� - `. � ... `-lay. T:St.,.)tit...�t.r-...r.:..r'S '�..ul .`t�.i�.ri�r..- T:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIALI! EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 30'll$1 �INZ'rY�b04aitsc)cu diiloio-:shiers -itecesnar`.'? �; ,.3z9' 1r _=.:
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To I DESCRIPTION color,hardness,uNrock rain sir etc.
ft. ft. G,
4.Date Well(s)Completed: �" Well EM ft. ft.
5a.Well Location: ft. it.
q �In L ft ' .r` 'a =L t'j
Facility/owner Name Facility1D#(if plicable) ft. ft. `! C
lurts ft ft
Physical Ad s,Q y,and Zip fL ft. � C^r5� O
��(�_�tX. WY�\ � �6 1�� :;�3?. e�u'Y:r'�-,"��a�;t� ..zi�o�,it,�, i 7 y ., ,�t F'".w��?F�'� �..: �1.,76 a.K•'.'
County Parcel ldentificationNo,(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweil fiPl¢,one IntltzMnv ic..cnfPtripntl
N Wllf� 7-1
6.Is(are)the well(s): ❑Permanent or ❑Temporary Sign:jiCertified Well Contractor Date
By is form,I hereby ceH6 that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: l fYes or ONo ISA Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the ofthis 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:
S.For GM o:Closed-Loop,Geothermal Wells having the same You may use the back of this.page.to provide additional well construction info
-construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells kdUtl 000 VVcl' 111 ACllMI"DVhf.1 VU Why 6t5U CIiAL•11 ddt];lUu.!pagosif-ae zssary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Lo© (fo Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dfferent(example-3Q200'and 2Q300D
op of casing: 16 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below t
If water level is above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
d' 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: ( •) Program,1636 MSC,Raleigh,NC 27699-1636
_ � to
12.Weftconstruction method: CLI� r dr�� 24c.For Water Sup4y 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 mmilea
FOR WATER SUPPLY WELLS ONLY: (� 24d.For Water Wells roducln over 100,000 GPD: Copy to DWR,CCPCUA
13s.Yield(gpm) 2 Method of test. �n d" Permit Program,1611 MSC,Ra eigh,NC 276 -1611
II
13b.Disinfection type: Amount:
Forst OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8