GW1--05718_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
(.4.14re- !^ PaJQ1 Pi SIUWAtf ikR/ZONtS1Is:r h. ^> '' .;."ifiO,``1 t't_' :`F hY IV +.ti-W/4:. '; �ti.i SF_.,' { ;�
. Well Contractor Name V FROM TO DESCRIPTION
r(
f� ft. ft. 1'
ar4-./ (, ft. ft.
NC Well Contractor Certifica on Number ,;15lOUralteSSINakfoi�1:tulti ed(welli)TORILINEW.(ifriij 1[Qjble)• rj)' 5' 4.
FROM TO DIAMETER THICKNESS MATERIAL
s f ��unit ( O,i)V 0 i ft. 9 ft. (QIldS'f° SbIZ2) VG
Company Na
P Y j ,f 17 Q , goiNER1e�A'SIN,CSloRausttoteeotli aiiiii'ewatloatims:v'zwIlgni,i.. .
2.Well Construction Permit#: /. -7 l d FROM TO DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(I.e.(IIC,County,State,Variance,etc.) ft. ft. In.
•3.Well Use(check well use): • ft ft. is
>+14 SCREEN tl °S `z t`.kris{r`'e'r'.t x"vWgi sn`$mM.M.i<. :`re✓M4ts 'L-IM
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. in,
)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. : in,
• °Industrial/Commercial ()Residential Water Supply(shared) ,YB:;OROU,)z "dooidt,A ob{.�..rt ,_ hitAa-.?; as.,.itzt wi....- �.'c
Il hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water.Supply Well. U ft. ft' h ert` e k'J . J 4 h a c n n tcL Pel
°Monitoring ()Recovery ft. ft.
Injection Well: ft. ft.
)Aquifer Rn'h.rge , ©Groundwater Remediation _ ph�;4_ti.
i 19'itdAVi ttvtlaAt TCY( pp Uodblers.,. M..w ±u.�"`i !;.- .MI ,W IAti ,i
()Aquifer Storage and Recovery )Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
)Aquifer Test • '1 ID Stormwater Drainage ft. ft.
DExperimental Technology ..'•,' 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer ;20 URIT7L" !1(rXiol;r(a(tobtiiaddlttuunllit eeti1ffiiecdabpry)n`:r';?W<;• it zi;' X&:
vnu al(Heating/Cooling Return) Other(explain #21 Remarks) FROM To DESCRIPTION(color,hardness,ealVrack type,grain size,etc.)
�, g a ( P © ft. 61 ft• clay` rajzl "nix
4.Date Well(s)Completed: 2l al(A� Well ID# /7D ft. co5 ft' OI '4Cnt e., '
5a.Well
)Locati n: f H. ft. U
—1 a- )1 *717/(. 5) / 4it rii e7 ft. ft. r
Faciilhty//Own1 Name {�' n Facility ID#(if applicable) ft' ft. ' t.":1 p".....!- „t=—�,_
,C C�s— 5';34,/ l k /JL./�Y Ff ft. ft. w'd(` V' I )
SEP
.
Physical Address,City,and Zip • ft ft t S EP Ti1 1 91 1 i
4;21ti.REMARKs a;.,'^:..,".`Ct t.. .`6l. '�2.a.7.at _.- o. te4',,l
Polk 7 hitr�,�r-,pr''(:J`!.i.>.ry
County Parcel Identification No.(PIN) i1, r u.4Y;��,; a i'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • • 4
(if well field,one 1st/long is sufficient) 22.Certification: I j
-?. I a.6 N — 1,Lr I .q l 63 W ,: -k �2 0-13
6.Is(are)the well(s)EPermanent or'()Temporary Signature of Certified Well Contractor. Date
- - - - - - - By signing,thts form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or !BIM with 15A NCAC 02C.0100 or 15A 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 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 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: 6-0-6— (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 r@200'and 2®1005 , construction to the following: ,,
10.Static water level below top of casing:: /P e) (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: oY (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y1.* 14-{^•/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) / i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
r
13a.Yield(gpm) Method of test: Q-/)4 24c.For Water Supply&Infection Wells: In addition to sending the form to-
t the address(o) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l'J i 6 r I YAP. Amount: - Crte completion of well construction to the county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016.