GW1--03759_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
a a it •\ rook
Well Contractor Name FROM TO DESCRI ON
NC Well Contractor Certification Number
` CO
Of A� POn,l� � � q�(� FROM TO DL4uM fER THICKNESS MATERIAL
Company Name V!!! VVVVVV YYP r 0 R' n, p In. t 1 %%
Q/� G31 �lI&VllVNL A'SINQ.ORITUBINr;(ke eerniel'clasedluo .. i (c `..::�
.2.Well Construction Permit#: t v FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(Le,UIC,Coun0%State,Var0tce,etc.) n• n• In.
3.Well Use(check well use): iy�ty� fL in.
A.i.UWlY•IGI.Y-1.,. � .�i_a}:� .. :.ti.Sfx. n.�•a A`, S1- .:li.�.��
LIOIAgdcultural
Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑p✓Iunicipal/PublicHeating/Coofing Supply) Residential Water Supply(single) ft. ft.mmercial ❑Residential Water Supply(shared)❑Wells>100,000 GPD FROM TO MATERIAL E6fPLA METHOD do AMOUNT
Non-Water Supply Well: ft. �� ft. 1,.- VI
❑Monitoring ❑Recovery fa fL
Injection Well:
ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
19dS •'AND/G
❑A Nfifer Storage and Recovery OSalinity Barrier
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage % it.
[Experimental Technology .❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer aOiDR GIUt; ditach"ada[tlon6 'feetatf"ri'eebsa ":' « t:.:: ,;r.
❑Geothermal eating/Cooling Return) []Other(explain under#21 Remarks) FROM TO 1 DESCRIPTION color,hatdne nil/rock tM,gMn 31 etc
La ft 0 I �
•i,iittLC VYWlkb)%.0111I11CiCUi .i -.0 2 "vveii iuit 1 --2 _•• 'j+V =.. - T kh±t.0 r txK-
Sa.Well Location: n•
FA VVU'r%
Facility/Owner Name , Facility ID#(if applicable)
ft. tG
I
j t C'I � W V Ia v. -LI _ JUN �202
Physical Address,City,and Zip It. ft. 1 �y
W M j v v
County Parcel Identification'No.(PIN)
(ifwell field,one lat/longis sufficient)b: �o,r..••�.:.-,�o���_o V� �v�•��w ::dc �_---
22:Certification:
6.I9(are)the well(s):1permanent or ❑Temporary Signaturd of Certified Well Contractor Date
7.Is this a repair to an existing well: ❑Yes or IdNo 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ythis is a repair,fell out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
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
,.L..q}..,.,.F..... ,...1..1 njll_] ;,.,�A...7 T.-.1:��ap Tn•r A T 1TI Tf!T•rn -_-c+ lAftf��CP.P.t /P!I/tt RP117AfYC 174MV1 Vfnl m .1-oMo�{.�d.i:
drilled: r 24.SUBMITTAL INSTRUCTIONS
9,Total Well denth below land s Tfa e.- 1 tr«A
rw mL9'-w w.eiiY im,aft nemm-it auierent re—win-maumu an/f 6lal i lip') wa.uliui►111r:
10.Static water level below top of casing: ® (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit.1617 MSC,Raleigh,NC 27699-1617
iyu.iur iu.ocuuu v VU'4; -.0 N Lu iwv ULLUrA Iuuuu iu a u�u�.VlllAUI au�11.Borehole diameter: b (in.) t -1 A
Program,1636 MSC,Raleigh,NC 27699-1636
(Le,auger,rotary,cable,direct push,etc.)
county environmental tealth dipREe—at of the county where Inst ed
rnn WATV o crTnpT V j1kTVT Y q ONT.V-
.::a a ��. '-..._...-:.�,c[:'.0=._:: :°'r[>an_-+r.� r.-'_•+-..:...., r•^lt^TTA
1ro ,1611 MSC Ralei h NC 27699-1611-
13a.Yield(gpm)�� Method of test: Perral P
��'�� I �am ,g '
i lao.insiniection type: A i v` Atnuuni: ` :s
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2011t