GW1--04378_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Welt Contractor Inforu/1m�/,atio�/nip:I D I , �+ y/��}�p
Jo_5on r oo\e 1�i /YiI GR'4 ISTEV ; N Y Y , .w� Y u4O , u i 4. gi tuff ,. , i,
We14ContractorName ` FROM TO DESCRIPTION
ft.
f•� 1 A �tr/ ft. �� 1 r/A
.
ft. ft.
NC Well Contractor Certification Number
1111tio ^ n15:QTFCB Ci±cSING(for iti!]tc-cagEil malls)bR> 1NER'.Efi ap Lcalile)
//��/� 4, jl.]t ' O )) FROM TO DLLLIETER ! THICKAFESS. lJ MATERIAL
Y of W,•` ' oi ft .T ft in r I trill
�(�
Company Name r ; ��.1`7. 4 1 fP%. Tr 4yV ill104
1� as���� 3 .t;IIVIYE titi8I DRlT:IDIINGT4iiitherinel;elose.-loop) , <t.::....1 -:-<+:_
2.Well Construction Permit#:Goj b a°i FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. IC,County,'State,Varl race,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: D YJ:.SCRZEIMI :. a. .Y, ° ',i34i ..g'_ MF _F;,,. zw_.';,.U, "i:,,a .. :,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑yiunicipal/Public ft. ft. _. In.. -
❑Geothermal(Heating/Cooling Supply) ietesidential Water Supply(single) '. ft. ft. • in. •
❑lndustrial/Commercial ❑Residential Water Supply(shared)
F,.xB.:GR:Q`4}T Mi-r .O 4::-5:R , .s.,rig._ 1 4:::.,..r.:'ri.:.- '- y,:
❑Irrigation. ❑Wells>100,000 GPD FROM r TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: L ' ,.k i,tomvft. � /1 fGRr n ��`1�• 1 aV� /!
❑Monitoring ❑Recovery ft V ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation '4711PISA:1101.0RA1tEL2'ACK`(tfnpgicabte) FF
❑Aquifer Storage and Recovery OSalinity Barrier - FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft... ft • .
❑Experimental Technology °Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 1:ZDsDRUstl G.10 (attach=additdonali'lieetsifiieeeesary) ^ .i ,4`,; _,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiUrock type grain size,etc.)
b ft. .56 ft. a,vitA )Nei
4.Date Well(s)Completed: ()".11 15 Well FD# ® ft. r 1,0 ft. a 5a.Well Location: . 8rh1
, r l5 V ��D 'lt��
h ft. ft.ft. 1"�: 4 ti .t''' 4, -...-✓ .
s 'Facility/Owner Name Facility ID#(if applicable) ft. {�
Z-Z-2S6 i eOL C _,-D'„- et /f 5a l 05 ft. ft. J�, ? 2l'Z�
Physical Address,City,and Zip !► AG 1 n d � ft. - -,..'a !if;1
J ��r t r
•
-:'2'1:-1tE1l3Ali104.'�.r.�,; ,x.k``{-gj:ii ga yj'i4 .l i4. x fgg.... Jc, �R + 7,..;
\1'aJci b1� �;514�0.
County Parcel dentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22..Ce ' atlon:
N w fc.viAsi--- 6 -1 b-73
6.Is(are)the well(s): dPermanent or OTemporary Signature fled Well Contractor Date
By signing this form,Thereby cent(that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo ISA NCAC 02C.0100 or ISA 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:
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 I 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 I 24;SUBMITTAL INSTRUCTIONS
• 9.Total well depth below land surface: J �® (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3 00'and 2®100�
10.Static water level below top of casing: au ,.. , 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617I MSC,Raleigh,NC 27699-1617
11.Borehole diameter Cg (in.) 24b.aa For Injection Wells: Co py to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Qi kiV 1 f OTar`t 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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) 3`y(�. i4151.11
p Method of test: 16 i b Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:11 V 1 Amount:_4112.14)_t___
Form Ow-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 5-6 2018