GW1--04376_Well Construction - GW1_20230707

WELL-CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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4;wtS'om...zicis: - u?r.<.prsin,;. + ftsa N y ot - .xo d po#
FROM TO DESCRIPTION
Well Contractor Name
:: °
• ft, .•
d n FROM . DIAMETER THICKNESS MATERIAL
GridPO6le \i,i& .li
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Company Name s ";1(rY.> RGSASTI�Tt;' iciT'CT�Ixk
Mrt6arrai clone lair7r,.r'',i `.€.?'v-IYA:isr'a..q
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2.Well Construction Permit#:(j •" - 053066 d.©),2 FROM TO DIAMETER THICKNESS 'MATERIAL
List all applicable well construction permits(I e.UIC,County,Stale, Variance,etc.) ft. ft in.
3.Well Use(check well use): • ` ft. ft. in,
F111,i])'.0 PJL}'!: tv—z h. ,F..�t?`�-.?-r- �si.1:.i.:: 4, ..+fi..,..o ic, '...�,A,,(,'aviiiiiA ._...
Water Supply Well: I FROM TO DIAMETER SLOT SIZE I THICKNESS J MATERIAL
•
// Supply(single)(Heating/Cooling Supply) 1i�Residentia!Water pp y(si gle) •ft, ft. I In,
❑lndustrial/Commercial ❑Residential Water Supply(shared) r� 4 .r - :,,:;:, :y
1$..GRO�f1:>�F}.z-a-�.1;,a�'��"���tca�.t?o-r,.. 1 m�e.a.:� ,:•.a,. .� .�.�'�.rx.i>....:,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL ErMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft' 1{' ft' •e.41-15 r11i !l�2 ra 0 7
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
t:"13-St I:il:G12A:'51 1 Pelf 1 (tfa~pplkibte},+•? ls. Z;.il .c,;.ile r °;;r.".' ,M!
❑Aquifer Test ❑Stormwater Drainage ft. ft. r
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 51th f iLLThtott1G.('attac'h_ad'diffoiul sitcetsifnece iait s) .,:AZbtu n ,;drys q*
FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it. To
ft.
9 Q
-'1
4.Date Well(s)Completed: �- Well ID# 3 o ft, j,0 ft- c !ell f -joc .
5a.Well Locafion: ft. ft.
e.v.DrItoo~ Pu01or 2
Facility/Owner Name Facility ID#(if applicable) fr. _
33.�3 1_.e.Uhq r61 KS_ .h ► 1 f- !L il51 ft. ft, - , =
9 y "M rIC()O
j L ft. ft. ,1111. U t - `.�
Physical Address,City,and Zip �J`.��7
1„tiulc� (7'12/ l�Vli 75 7r3v:1t.114ARIS.-hI W'z-T.+.;;�.s i:; .vF! 1' s?.: .> £d' ira, x . 'k'. .tiA'k;;"-`_a'',f'i'
Conn Parcel Identification No.(PIN) I[t,, lr a ` i '."' ,
(if well field,one let/long is sufficient) 2''It CerrtificatIo j '=�
N W V 1/ �JO(k- —2 i-23
6.Is(are)the well(s):.QlPermanent or OTemporary
Si, Hire of Certi d Well Contractor Date
By,gning this form,I hereby cent fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown 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.Par Geoprooeillt'a.or Ciosea-Loop Geothermal Wells having,um aaura — -
constnictipn,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: f // , 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: b 0 (ft.) Submit this GW-1 within 30 days of well cotnpletion per the following:
For multiple wells list all depths if different(example-3@200'and 1@J 00')
`
10.Static water level below top of casing: 0 • (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
�
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
„__ 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: q i r rotary 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) 1a .{�h Method of test: °�W Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: /IT ' Amount: 2 [11
Form GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018