GW1--04375_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ••
1.Well Contractor Information:• /
6LJ®r] PO 6 1 e/ 614fWE'I;E11,7it X'1:s?F Y,;;;.0` ';+lr .: 5 •' .b.. +.!'3'.:`gegi`-'?: ? , ,Y:Fa?,
FROM TO DESCRIPTION
Well Contractor Name
(1 1 A . it. zoolt. 9] 3 f
ft. it. �`
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FROM TO DIAMETER THICKNESS iMTERIAL
�� ra D� �/ ki)i2.� . foil l/tI t 0/� ft 55 ft. („ in. p O U 1'
tiq tra
Company Name ,.,_,41. ( :,,.< b y
(�( n `� *A6 IL7NFAR A,SIIY,ailellvO l46:;(0a liaiiral(closed'_lioopk<... ^�a'r�.n.;.:"'Rol
2.Well Construction Permit#: w e q o q 3 9. Q-'`)?a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consruction permits(Le,.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
IWater Supply Well: a. 7`<,SCREEk�t' +i�u' u�li ec A,. i:"e?'-u,;',.,: '".' -lt" --j i##::-,cw,7`s u�: •,f"'r!,f_!
1 FROM TO 1 DIAMETER1 SLOT SIZE THICKNESS I MATERIAL
❑Geothermal(Heating/Cooling Supply) tftesidential Water Supply(single) y 'ft. I ft. 1 In, 1
❑Industrial/Commercial ❑Residential Water Supply(shared) ,�,S ii O`(1T�, , -, S:n ];x t i er , 3, ,�O ; , 4;_ :3�,s,
.,1 R . .. .�,, w�, +r �r�_.. .Air. .., .�: �, r r.
❑Irrigation ❑Wells>100,000 GPD FROM TO ATE EMPLACEMENT &AMOUNT
Non-Water Supply Well: b ft. a0 it. r4..( j '/av ;'❑Monitoring ❑Recovery ft. ft. CCCC��� y
Injection Well: - ft. ft. •
❑Aquifer Recharge ❑Groundwater Remediation _l g.a 4'•: ti z fi g
x3cSrlYA/C;121iLPAt'KfaPpLlcabI .. ..f cc ..,. 2. r.� .,. .-
❑Aquifer Test ❑Stormwater Drainage ft. it. 1
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer i1lirAtl tin r(at€acfi ddtiionitX sheets itneces ii6 4 cs.•gmaVR_i .ii
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a it If
I Q
4.Date Well(s)Completed:it I -�2 Well MY D ft. aft tii t f e rbc
it. ft.
5a.Well Location:
//ye�taA►► __ .- __._._ ._ .. ._.._. _._. _-.__
Vi/O
s ` -°'`"' 'ti
Facility/OwnertNatue -7acility ID#(if applicable) ft. ft.
13'3.51 M P]lb f 4inol'kj Rd , �1,C I b f. n. J�1! 0 ? ZU'L3
Physical Address,City,and Zip 1 . ,, „
r1 i'O$
tL is-
C/ •At.l+ yHl7. a i_rm7 x L?} tz.f sd St rlikv
Cc ty
Parcel Identification No.(PIN)
9.
(if well field,one latllong is sufficient) 22.Certification:
N W ,1 6 �j5- Z1
6.Is(are)the well(s): Permanent or OTemporary Signaof Certified Well Cont�ctor Date
By Si_•ng this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lNo 1SA 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 of the 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:
•S.ior"Geoprobabi-T or C:lawn--Loop-Geutuenrrai iireiis-ilavtuy'iirc-sztutc• -
consttuction,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: 1 24.SUBMITTAL INSTRUCTIONS
r f�
9.Total well depth below land surface: ' V (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different ent(example-3(0200 and 2®100')
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
If water level is above casing,use"+"
N. 24b.For Injection Wells: Copy Ito DWR,Underground Injection Control(IUC)
- -- - IYJ „-
12.Well construction method: art- ir0 4 qy 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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 DWR,CCPCUA
13a.Yield(gpm) Method of test: b ®� Permit Program,1611 MSC,Raleigh,-NC 27699-1611
•
13b.Disinfection type: Il1 In Amount: -9f 11 i b.
Form GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018