GW1--03912_Well Construction - GW1_20230612 (2)

4VALt CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name x TO DESrRYPTION
i ft. I,;IS ft. q
r R5�rE_ __30%L_ 9312
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NC Well Contractor Certification Number N 2023 'L 1335 ft I A 34,7, 6 AU—N
- FROM TO DIAMETER Well Company, Inc. 0,
ft
Company Name in. Paj
2.Well Construction Permit W:�j s.K 1-7 oa.r FROM I TO I DIAMETER I THICENESS M4.TM;ffAL
List all applicable well construction permits fl.e.&7C,Cowity,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): IL ft. in.
Water Supply Well: FROM TO DIAMETER VY SLOTS= I THICKNESS rMATERIAL I
OAgdcultur—Z 13MunicipaVPublic ft ft. in.
1:1&offiexmal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft. in.
01ndustrial/Cornmei al DResidential Water Supply(shared)
DIrrigation []Wells>100,000 GPD FROM TO MATERIAL ENTLAMOENT MMTHOD&AMOUNT—
Non-Water Supply Well: "- 966
ElMonitoring ElRecovery ft. ft.
Injection Well: ft. ft.
ElAquifer Recharge ElGroundwater Remediation
I 19.SAND/GRAVYM'-TXLXr(iLf
DAqnifer Storage and Recovery ❑OSalinityrDarrier FROM TO MATERIAL MMILACEMENTUMTHOD
CAqnifer Test OStormwater Drainage ft.
ft
ElExperimental Technology ElSubsideace Control ft. ft
Meotherroal(Closed Loop) E]Tracer '10MIUMNal G(iitficl
10 Geothermal(Heating/Coo' g Return) DOther(explain under#21 Remarks) FROM
TO DESCRIPTION(color,harduas,sailtrack typt she,atc_)
Date Well Started I R//Mq:f j'?J-j lo ". ft Soar I
4.Date Well(s)Completed: 7 at well iD# AAP--6 P —2 ". 6...A
51.Well Locat1=­,,,,, Phone 2- 2-20 *3p 4--e-�j
Facility/Owner Nama 'r Facility M#(if applicable) D ft rt It
Vt yap ce 7\5 Cj P%e_,p V j I IA. fL ft.
Pbysical Address,City,and Zip ft fL
county Parcel Identification No.(PER)
5b.Latitude and longitude in degrees/minutes/seconds or decimal de
(ifweH field,one lattiong is sufficient) 22.Certfficatio
34 , 2-1 6'76,'l) N 9be -V? ICC3
. 6.,6.1s(are)the well(s): Effermanent or DTemporary Si Extified Well Contractor Date
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Igningthisform,]hereby certify that the well(s)was(were)constructedin accordance with
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7.Is this a repair to an e-�dsftg well: DYes or )(No IJA NC,4C 02C.0100 or 15A MC.4C 02C.0200 Well Construction Standards andthat a copy
Ill out known well construction information and explain the nature of of this record has been provided to the well owner.If this is a repair,f H
repair I finder#21 remarks Section or on the back of this form. 23.Site diagram or additional well details:
having the same additional well constructi
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells ha You may use the back of this page to provide m info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box)-You may also attach additional pages ifnecessary.
drilled: • 24.SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: 7 0 e), (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iflifferent(example-3@200'and 2@100D
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617Cn
11.Borehole diameter: 6AS -0n.)Bit Off- 24b.For Injection Wells: Copy to DVVR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-163 6
12.Well construction method: it 24c.For Water Supply and Open-Loop Geothermal Return Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DWE;,CCPCUA
13a.Yield(gpm) method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
L.0
70% hth p , of Date Site Visited:
13b.Disinfection type: Amount: z Site Visited By:.
Form GW-1 'i na Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: