HomeMy WebLinkAboutGW1--04377_Well Construction - GW1_20230707 • •
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
3aSoV PP to„VGATF.It`zt,lesgi. .art,. 1E.,_ W(War°fir.. ,.n. ''„i:rr °_..>r
We1lContractorName FROM TO DESCRIPTION
?:a19A ft. Vft. t1 jr�
NC Well Contractor Certification Number N f k: -H4 p t`..gTN!"tfisli _. H, ki . I VOR.r IMP.P.4,4iii•5Co'gkYn1 ._ , <. k f ,-.
�Er1 ,fit We t h �y FROM 11 TO IIf•DIAMETER fII THICKNESS iKili I1 MATERIAL.9
.f �'��l�� Y 1 '11 dvl� <Ad• ft I �® ft. I m I 1 ��V11
' Company Name & f�op e J I
fiRt--, B 6 /A ICII1�11?1BR C,ASIIY UIt F.tJSI15,1i,(geiiiiii`mal"rtoiiifilliitiY ,xr_�_4:,....„ `:.:
2.Well Construction Permit#: &LI - ! 0 .. ' •- `� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Vai4 Stge;etc.) ft, ft. in. .A g i �/�R a y V t 1 I, flErr•
4
3.Well Use(check well use): ; N` ft. in.
Water.,Supply Well: • 7.;SCR>aEN; :c: E :... , r: r,�. .:,;., 1„- .>: '4`...g,,� r., ;.t
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural ❑I_ylunicipal/Public I_ ft ! ft. I lh•..'�
❑Geothermal(Heating/Cooling Supply) i}Residentiai Water Supply(single) ` '`ft 1 ft '
in.
❑IndustriallCommercial ❑Residential Water Supply(shared) AktittifiT ,, .:=.. .N k.-W:C1.A W _ s
❑Irrigation. ❑Wells>100,000 GPD , FROM TO MATE EMPLACEME METHOD&AMOUNT
Non-Water Supply Well: • 0 ft' 20 ft be i`{' , .5ram!.
❑Monitoring ❑Recovery ft. ft. •
Injection Well:
ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 14-BDIGRA VEtAG :(ifsppAribfe} ,, .-_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL 1 EMPLACEMENT METHOD
1.
❑Aquifer Test ❑Stormwater Drainage 11 '
❑Experimental Technology ['Subsidence Control ft ft. 1
❑Geothermal(Closed Loop) OTracer 71Ij33;'LING'•IiOG:(atta'Ilcliadd►tiiiiiiix sheets,iiireceseii y}:, 'r' .�x 5 `
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,so3Urock type,grain size,etc.)
d ft. 60 n• jet hd
4.Date Well(s)Completed: 5' 30 a;/-5 Well ID# 642 ft. % ft. 54ifit .. A•Z
5a.Well Location: Si) rt. ® ft. 9rd..,g1f� �Gc
il` 044 ill it i%- 6o. Y; ."a 4 1-_.7. = r, i. a..:.:r.,,,-_-) L.
.� ft ft. r, r.•..
Facility/Owner Name F cility ID#(if applicable)
1O®� PJ e r� KA t i4 o I.e /545 ft. ft ,;,, Q Z�I c3
Physical Address,City,and Zip 1 f ft. ft. i ,.ar�..;.�,I.'' Uri
U a.) . I Th e!"%3'1 1 J t�, T(t' lr i r r •o r 7 .21,- n -
�1:itir•M�S.Ii7($. sic. L.. a .:.3F ie+uC v�,^ d � '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
iii weii ileiti,-uc iarnang is su noicu1 ^ication: " — ..
• N W /... :c'e/ +s♦ ` C "3f3
6.Is(are)the well(s): [Permanent or ❑TemporarySi of Certifiedll C!rector - Date
� signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 4To SA NCAC 02C.0100 or 1SA 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 swell owner
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You!nay»se the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (auti'Sce vvcl'ini'Rcuiaucs Box).Youluay also attach additional.pages if necessary.
drilled: I ,. 24.SUBMITTAL INSTRUCTIONS
d,
•
9.Total well depth below land surface: 9 ® (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2®100�
a0 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"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Pmnrarn 161.6 T`,rc'Ra1'ir,h_NC 77649-1636
12.Well construction method: C l r r01— 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: r 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
m C �W Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield
(gpm) L 11:: Method of test:
��AA I y�!! I
dL 13b.Disinfection type: �� Amount: 1 �' 14 I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018