GW1--05727_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well/ContractorIforma on:
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Well Contractor Name FROM TO DESCRIPTION
ft. tit. i
2_136 /.
ft. ft. i
NC WRIT Contractor Certifica'on Number
L//-fl nv ///���[ 1 v' '1MOUTERICitSING4fdidilbi1,1HAr'c�iteiliivepb)TORR?Y/RIER}�fi liiiible) ?
l��✓ Pii �N�P lJr/ �l/{C . FROM To
U / y�R JI)C SS MATERIAL
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Company Na • Cr16 1MVER.CIrti
O_'-ORS lU13. INO!'atailiiiiiri akiiiiitgbe— .4..,'` ;g•IC %W,'',><.'
2.Well Construction Permit#: S I —D l /g FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): • ft. ft. In.
Water Supply Well: t#175SCREENi d"_ 's t' ' d=fit44. 1:7ff(.:; r .��s �? �n. .<�'�4? u n
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
■Agricultural [Municipal/Public ft. ft. in.
•Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) fA ft. tn,`
■Industrial/Commercial DResideathil Water Supply(shared) ; >i:tGltOiitt n'EF .`.r?VAMa 'rM'a a3'i':7 ,'.;r.'.4t' :as sigiv't ;,
Irrigation - FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: _1 t2 ft. d 1 ft. I)e-/t,r{'tltC� • /2 he S - 6IW,j
Jr Monitoring Recovery . ft. ft. `1 /
Injection Well: ft. H.
A Aquifer Recharge 10 Groundwater Remediation
49 SAND/(lIt'AYEOPA i (ifiaiiPUeable)2'.;,? Iit'g k?_,V41 ,._a ..rs
*Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
)r Aquifer Test ` `.QStormwater Drainage ft. ft. I.
■Experimental Technology ;,Q Subsidence Control ft. ft. 1
•Geothermal(Closed Loop) . OTracer N2 W. tti a o ers tilif)3Eeei a o nRllit;nytc�i:o (ti; .��,aalq b tine �i�) .���.-;w�, ���
" 1(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardaeee,rolUrock type,grain size,eta)
_ (H g/ g [Other(explain under#21 Remarks) 0 ft. 7 4 1t. s•ix I 1 _I i!-t�Q.yt •
- ---„,-1.,.._,—"" s)Completed: 2S'"1 r 3 Well ID# lPP r ft. //�/5-f* .i e .1-1 f e,
5a.Well Location: ) p )A J /
ft. Z`f' ft. 1. /
DD 5G/� „,,,,_ / {�CSA, h) , �-(�l.L'�/ ft. 1"i,!"Q .F.: +Air: 2'~'),
Fa Name j!1 Facility ID#(if appucable) R' ft.
�3 l'Ye Glr .� 1.41... �t'� t/1CIA) ft. ft. SEP d a 1023'
Physical Address,City,and Zip ft ft. i
/�/� /� / r �0 /C 1r1 r"7*gyp �• �,c-•�Py Ur-
/ c L la(�e-i ! 04.1.EMARKS:^n . i7-:0e,: ..,.t `' 'k-.',.; e.ii -t.... a� ,, - •
County Parcel Identification No.(PIN) •
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • ' .
(if well field,one lat/long is sufficient) 22.Certification: I;
SC,6-51.3.g),2- N ""$l' giq 4 w ! cjafrift;" Cciltioi i
•6.Is(are)the well(s) Permanent or `Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existitig well: DYes or gigNo with 15A NCAC 02C.0100 or 154 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 I GW--1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: � ( SUBMITTAL INSTRUCTIONS'
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9.Total well depth below land surface: lP (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 pleasing: • d( © (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: t t? (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rota_rabove,also submit one copy of this form within 30 days of completion of well
construction to the following: i
(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) _") Method of test: i 1A 24c.For Water Su alv&Inlectiont Wells: In addition to sending the form to
f e the.address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l/l2/6 Y/K e. Amount: G£I_45 completion of well construction to'tiie county health department of the county
J where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 • Revised 2-22-2016
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