GW1--05220_Well Construction - GW1_20230818

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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t WATER NE§.T."rVS?r`., 1hgri3i lc,rWr;`7...r,ha . J...r g. ,, ;: t
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I ,
r! ✓ /,5- A ft. ft. H 1
NC Well Contractor( Vl)Certti/ficattiion Number /► 16:SOUTiR{t AS1I C5rY(for mi111ieeY`aa iellii)i 4I41 RI,(I!':njl"tit 3y1�)�^_i? x •:-'"
/jJ / /'/D f vL� 0- /' _/ :TA G/ FROM TO DIAMETER THICKNESS T .S MATERIAL
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Company NamE/ ��) !J n / ' , f.46)CNNERIf1ASII!ioolt;' uiti1!tt~ir ed46etniiitdosed#li�gp)w 41,-ss`-'4nAt i ,r>:<'#{"
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2.Well Construction Permit#: � - ! D 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
• ft. ft. ' In.
3.Well Use(check well use): a may, k} f , ;TMtilxrx n,., r`V
Water Supply Well: $FROM v 7 .DiA¢R'tsLo SIZE THICKNESSj MATERIAL
Agricultural 0 umctpal/Public It. ft. In.',
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. In.Industrial/Commercial DResidential Water Supply(shared) igifitCRUU7'. ? ?i3li.,stiy;:. aV;uk r.. :;';re c s-.;>,"::
• FROM TO MATERIAL • EMPLACEMENT METHOD&AMO
� IrriEation i / i--{- L
Non-Water Supply Well: Q ft. �� it. b'_'(�eli)/Z. 1 3,baj../o.u ve.
Monitoring Recovery ft. it. v
Injection Well: it ft.
Aquifer Recharge QGroundwater Remediation 91SA1 D/QRA iI"AUt2O1l inAeabtQ)'u r.,.1 r :•� • `' i:k7, ; ... r.:
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL- EMPLACEMENT METHOD
Aquifer Test •`.�Stormwater Drainage ft. ft.
Experimental Technology .i..'• Il11 Subsidence Control ft. ft.
Geothermal(Closed Loop) $Tracer gS06DIiif3111/5G I;OG1(ett.eNill010quplliitee6}lfijkeeeliar3!)SIMW + -. r Y +`{
FROM TO DESCRIPTION(cotes;hardness,toil/rock type,grain size,etc.)
Geothermal(Heating/Coolin/JgRetturnn) Other(explain under#21 Remarks) U ft. it. '
4.Date Well(s)Completed: < ✓ --°�3 Well ID# /D !--)ft. :71' A ritYC/�P�
ft. ft. ZJ .•+�
5a.We Location: f t ft. (- ' ww s
arcs onxit, igArre;t4 l � �.. � ' :�.:
# s applicable) ft. ft. AUG 1 $ 7073
-Facility/GlwJner7Nacma ear�,y'/1 Fa/c1ili�fty�rID (ifpp )
ll/L/ 5 Lam+ t /iLS/Utie, h�/' ft. ft. it r�r:K.sswrgy Ur.
Physical Address.CCity,and Zip tt ft. i 0/
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one Iat/long is sufficient) 22.Certification: 1
*-6—hl44 N ' rWSignature of Certified Well Contracto4cui
Date
6.Is(are)the well(s) ermanent or Temporary - - — -
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo • with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided'o 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 site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
. drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: s.J ram/ (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3®200'and 2®100') - construction to the following:
• 10.Static water level below top of casing: gU (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use""++" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: J O 71—.4 2f above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
- Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: t 1636 Mail Service Center,Raleigh,NC,27699-1636
' 13a.Yield(gpm) 3O Method of test: 11-I N . 24c.For Water Sunaly&Infection''Wells: In addition to sending the form to
e the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Ck//)r I n E Amount: t -5 completion of well construction to the county health department of the county
i
where constructed. • ' 1 .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources t ' • , Revised 2-22-2016