GW1--03931_Well Construction - GW1_20230612

WELL••CONSTRUCTION RECORD (GPI-1) For Internal Use Only:
1. Contractor Information:
RreiiContracro'irame FROM TO DESCRIPTION
ft. COW
it. ft. I
NC Well Contractor Certification Number
p� i�.�yu�E4:.0 1S1wG fdrmtsttt�Esec iiellsl UHZLINEIz�f: licabte
Y illep Well Drilling FROM TO DiAMRTF.R THICKNESS MATERIAL
�i 1 9 % , in. 0 9� �( C
Company Name .bJtE?Ie.E2'Ci✓N�fll:rl(B)IR.G%.{�etitnei�itiaE.cFuSecF(Euo ) Y V
2.Well Construction Permit 0 MAIMETER MICKNFSS ntA rr:Rl.v.
List all applicable Nell consiniction pennies(i.e.UIC.County,Sfaie,Variance,etc) ft. ft. in.
3.Well Use(check well use): [t. ft. in.
Water Supply Well. FROM I TO DTANIETER I SLOTSIZE I TRrCKNE.SS I MATERIAL
❑Agricultural ❑❑MM�unicipal/Public ft. ft. I in.
❑Geothermal(Heating/Cooling Supply) Ix3Kestdzntiat Water Supply(single) ft. it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .lfiiGE dkl .
❑Irrigation ❑Wells>100,000 GPD FROM TO" 1 MATEMAL Fn4RLACENMENTURTHOD S ANIOliNT
Non-Water Supply Well: ft. ft• y 1, "g, t g
pP
QMohitct*ing ❑Recovery `D ft. j� ft }}a
7 2 7 C,_
injection�TD'ell: ft. it. I I
❑Aquifer Recharge ❑Groundwater Remediation -g 9
t ' NL:?�Az*S lz�:a»iuC^lile}
❑Aquifer Storage and Recovery ❑Salinity Barricr FROM TO MATERIAL E13PLACE�•IENT METHOD
❑Aquifer Test ❑StonnwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) El Tracer 20 E1R FiN:Ga OG:(attzcliadciiiai t li eti>i€aee s ivl'sEsr<>::>.<:: ><rr<>i>'«'> £z:»'63:
MOM TO DESCRIPTION(color,hardness,soillrocl tv a 8
❑ m Geotheral(Heating/Cooling Return) ❑Other(explain under 21 Remarks) r2i¢size,el.1
'mil
4.Date Well(s)Completed: �.2( ! Well 1Dd V ft. r (J(f ft.
�
52 a Location: ft. ft.
@d�{. 140, s4nnJyyr(
Facility/OwncrNamc / Facility IDR(ifapplicable) ft. ft.
1
ft. ft. I
' id ity,and Zip C ft. (t
tjljfe.
.S4uliil7i T7 R.i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/secunds or decimal degrees:
(it'well,ficld,one lat(long is sufficient) /� �j 22`�CC 7,ication.
I., _4`0(",x N _ 3 7 !)'. / & W
6.19(are)the well(s): E?Permanent or ❑Temporary Sidgnaturz of Certt red Well Contractor Date
3;s{•,ming this Jurnt,!hereby rrrrf p Char rhr rat-11(.cJ was•Irv'err)runarrrr<ted ir.ur;z,rduncr a-.'th
7.is this a repair to an existing well: ❑b'es or Iffi o 1S:?.NCRC 03C,0100 nr i?;l VC?C 01C.0100!ell Construction Standards and that a craps
{ftha is a repair,fill out kxo;sn well construction injbnnation and explains the nature oj'thc of this record has hcen provided to the cell oimer.
repair under#21 remarks section or on the back ofihis form.
23.Site diaorarn 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 MV-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:
�j 24.S'UBYRTMU INSTRUC17ONS
4.Total well depth below land surface: {%l! (ft_)For multiple wells list all drptht if different(example-3 et200''agyn�d 2(5100') Submit this GW-1 within 30 days of well completion per the following: -
10.Static water level below top of casing:-- (€r) 24a. For Ali Wells: Original form to Division of Water Resources (D'WR).
!fw'aterlevel is above casing,use"+" lnrbrmarion Processing Unit,1,61Z MSC,Raleigh.NC 27699-1617
11.Borehole diameter' °) (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,,NC 27699-1636
12.Well construction method: F �PJ G2YD j V
p.c.auger•rotary,cabto direct push,ctcJ 24c.For Water Supply and©pen-Loop Geothermal Return WeIIs Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells nroducine over 100.000 GP:Copy to DWR,CCPCUA
(,pm)— iddethod"of test:
13a.Yield a m ,y� Permit Pl•og rn,1611 MSC,Raleigh,NC 27699-161 1
f a ' 1
13b.Disinfection type: T 61 Amount•
FormGW-1•
North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-201 S