GW1--03915_Well Construction - GW1_20230612

L]L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
`�-
.our x y V :i 3 w^ :']4:,WATER ZONES° li:. ::.:..: . ...... :..
sFROIYI TO DESCRIPTION —1
Well ConhactorName 4 j' IN' 1
� '�7 h-^ ft. ft
D t JU d 2QZ3 .. ft ft d®_
NC Well Contractor Certification Number
15:'OIITIIYCASIl`IG-
(f6r'mulli=c�sed'tiveIIs:OR'Id1QF�i£a'licalile _ " -
Yadidn Well Company, Inc. MATERIAL,
!ti"�'a,•l.� ,,,�,.;Company Name ft. ® ft OR
R- u 21
:-
�p t� INNER CASING*
OR
2.Well Construction Permit#:La]S 1 \ t' 1-51(-S'7 1 -7-J 2- 1 FROM TO DLUnMTER THICKMESS MATERIAL (�
List all applicable well construction permits(�e.UIC,County State,Yarimu e,etc) fr ft. m 57
3.Well Use(check well use): ft ft in.
Water Supply Well: t-.1.7`
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. ft in
❑Geothermal(Iieating/Cooling Supply) Residential Water Supply(single) ft ft.
❑Industrial/Commeicial ❑Residential Water Supply(shared) 18`GROUT."':
❑Irri ation ❑Wells>100,000 GPD FROM TO MATEIUAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: h
fi. /),,� ft / 1 � I
❑Monitoring ❑Recovery ft +� ft ry
Injection Well: V
ft. ft
❑AquiferRechazge ,❑Groundwater Remediation
i:19.SANDIt'>RAV.EIsYe1GICrPa"-liralili: :.._ _ _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20:DRIYSZNGI OG iittach a2ditional's3eet+if nece�s _ _ `
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,Hardness sail/rock type,grgin size,eta
Date Well Started IMMW I Q 3 o
ft. itsft. r a � &0
4.Date Well(s)Completed: Well ID# - C 2- ft. fL
Sa Well Location: n 1 Phone#3,3G-'-®!.3-3t7�' t ft. 9b�ft Z � � .� s le
�Glfd 1 r0 V C�C�MI OI(�t'Z ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
310s ft. ft
�Ptri�(il r zG✓� L�
Physical Address,City,and Zip ft ft
XC14<;n
County Parcel Identification No.(PIN) 1 v y C` ®�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lathong is sufficient) 22.CertiI
36, (�77t9� N 9D 7 /1/y'
_� of Certifie eli Contractor Date
6.Is(are)thewell(s): L7Permanent or ❑Temporary 1 �
By signing this form,I hereby cerh,fy that the well(s)was(were)constructed in accordance with r'1
7.Is this a repair to an existing well: ❑Yes or I_'1No 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy "f
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 421 remarks section or on the back ofthis 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 L
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Youmay also attach additional pages ifnecessary. �R
drilled: 24.SUBMTTTAL INSTRUCTIONS "C
9.Total well depth below land surface: F/(7 _(ft.) Submit this GW-1 within 30 days of well completion per the following: d
For multiple wells list all depths ifdifferent(example-3Q200'mid 2(a3100)
�+
•�� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 't If water level is above casing,use / ` j
11.BorehoIe diameter: C.� (in-)13it Off-. Fv.®5-( 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
�® Program,1636 MSC,Raleigh,NC 27699-1636 .t]
12.Well construction method: /T �'' �� — 01 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush,etc.) county environmental health department of the countywhere installed
CA
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1"0"GPD: Copy to DW1�CCPCUA
(gp ) 3 Method of test: All- Permit Program,1611 MSC,Raleigh,NC 27699-1611 � �
13a.Yield m 5
70% hth Date Site Visited:�.—�—�..Z e.`"`k`z�.4'
13b.Disinfection type: Amount: OZ Site Visited By: ,011% P 'wh °� ✓
s-Ljlt,-�
Form GW_-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price:
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