GW1--03716_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ;
C 1 so IN �fJ d L 1�/ 14;WK T$R=ZOlYE3 5 tip..: w'
Well Contractor Name FROM TO DESCRIPTION
ft. '
NC Well Contractor Certification Number
.45.0UTF.R,;CiS'SING'formulh-caSEdwells'ibR'I;1NER''.'tfu'"-licelile �.}-_, ,-
L� FROM TO DIAMETER THICKNESS MATERLU
V ft. I IL in. P�
Company Name
•{ ( 0q.
� � .16;TNNER;':CAS1N OR�T.US ; "'eotherin"`dosed-Tbo` z F i ,�;;4z
2.Well Construction Permit#: q 40 2®73 FROM TO DL METER I THICKNESS TERIAL
List all applicable well construction permits(i.e.UIC,Counq;State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public I,. ft. in.
❑Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft ft in,
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18:'GROi1T . ,
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERUL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft. ft. q-
[]Monitoring ❑Recovery g %
Infection Well:
ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salim Barrier FROMIVLLGRAVEtEAC'f Mn FRIALe P
q g ry ty FROM TO MATERL\I. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. tr
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer20s`I1R1LL1P1GTs'v 'atiac7i additioaalsli'eefs if necess"" +
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM I To DESCRH 70N color,hardnes soil/rock type,
_ rain size,~ete.Ln V
it. ft.
-. __.
=r.iiiiYii nciiiaj-0myiumci.Ci _ 1-o-,. iibli iijw
5a.Well Location: too ft. Q ft _Q rkm rte—, rr e f_=�-
Facility/Owner Name Facility ID (if applicable) It.
ft i
_ - - - __- ��►� G v 2023
Physical Address,City,and ip ! ft. ft.
��.✓11��i ..+T,1�1ZL1!'1,KI21�S:�i!.-. ,.. :�.:. .a_:.:c?. '. ..7.::. ..+ti.�, „'.t�:..`.,� ;; ;s
County Parcel Identification No.(PIN)
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-- - --- -- - - u..-_---- ---------y IJG-Vl\4J Vl dounflul tiUgrCCS: j
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): [Permanent or ❑Temporary Signature of Certified Well Contractor Date
�r��s^�rs crrsie�%�.%�cr.r�Y cc,ijy iiiui Lire weiiisj was�werej constructed in accordance unik
7.Is this a repair to an existing well: ❑Yes' or W�o 15A 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 ofthe 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:
8.For Geoprobe/DPT or 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 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: j� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: q 0 0 (ft.) '
For maltinlp walls List ell de„the!rrep#r•oxr(n,_amnte--gn2nn,a«a?n Innn Submit this GW-1 within 30 davg of well rnmnletion per the fotlnwrnn.
rr o 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5tatic water level below top of casing: ft.
If water level is above casing,use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: .r rav,Y
24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the
(i.e,auger,rotary,cable,direct push,etc.) county environmental health department of the county where install. Copy
FOR WATER SUPPLY WELLS ONLY:
1 i 24d.For Water Wells nr.duc no nyer 100,000 a n.rnn.�rn TM.M.r,rp�TA
1 11
V ; .,"aicl6it,ii,t7U77-1 iY0i 1
-13a.Yield(gpm) 1 e�- Method of test: iV V.i iriQ�
. ,
13b.Disinfection type: Amount:_41a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018