GW1--05763_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
&dur yt Ll. I.-G-49 l✓ ii:lil'CI'Ar11ERt7A1VES/r, 1 r gl'h'kl,rM4'."...gz. .,si:<k WMVg .-',11+r4V1
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
454 5"A ft. ft.
NC W IContractorCertificationNumber ///��� /� �� 15i; UfitETIiCASiIt�'(f3%amiillisCaeeiY`siY011ij10R1LtiINER;,(tt?ap HcSfl3lb) i ='•:f
_ m / t / 1 � /Jg.h ./� / 'D , IxG. FROM TO DIAMETER THICKNESS MATERIAL
Company Naafis
/ '16:i7NNEWCASf1V'G'OR' 111. .(4eotbei0itolt'ilo@Cdtl6Op)'?f-'^•;'ii;-'t%t.Erg q-li.%- e,
2.Well Construction Permit#: / ) /Z C 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): h• i< In
t17 lgQRFiENia fw;r:C ft.I,W-3 TITAN I'll ,'�5�.`/00 .n:� i ik fs-/.45
Water Supply Well: FROM TO,, DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural OMunicipal/Public ft. ft. In. '
13Geothermal(Heating/Cooling Supply) giResidential Water Supply(single) ft. g, In.
[lndustrial/Commercial DResideatiat Water supply(shared) MII;( tQr 4.,(kVr =•4-10:^..t3xcyjUSR.Tgt ; �>�#_`•�sz rV g+a lli
I-"Irrigation FROM TO MATERIAL- EMPLACEMENT METHOD&AMO
Non-WaterSupplyrWell: - 0R' � f. 1)()_t'4((;.y(! !e -/ h�5-"]0 Diet
. °Monitoring ©Recovery ft. ft. I
Injection Well: ft. ft. • ,
pAquifer Recharge Q Groundwater Remediation , 9i(SAN)1GR'Al!E/144016(ifitRpUca(ile). ggiba.&MKM4 7x-bs v j Ma l
DAquifer Storage and Recovery II Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test \,`.3Stormwater Drainage ft. ft.
' 0Experimental Technology "".‘111 Subsidence Control ft. ft. '
Geothermal(Closed Loop) DTracer '2oHiftIlit 01OG:(att etk dill ofi'1 heiti itn6ceseiiit) . 1.A: ''te ham=
FROM TO DESCRIPTION(color,hating,eolUreak type,grain On,eta)
Geothermal(Heating/Cooling Return) Jt Other(explain under#21 Remarks) ft. q ft. ,S/tr''l 1 �/a .
4.Date Well(s)Completed: ?"1- /
/'7 -A3 Well ID# ),.-3 at. 2C2 `,� -Yl Y - -/ te-
ft. ft. LJ
5a.Well Location:
vZon (.5 -ru4;e! ' it
_ Facility/Owner Name Facility ID#(if applicable) R' ft. IX�
/ • ^ ) ft. • ft. a 1 2023
lbl2. �ah-�. V�5`��r ��v�sMtrr, SEP
Physical Address,City,and Zip ����ft. , ft. t�„.� µye y
d.IliYRE1�1f}1�lN,,,, '„,,, ,a ,t.(-�Rs'"`R w�$Y``•li,,m, *04,*S 3: .:f
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one 1at/long is sufficient) 22.Certification:
5-. I qo' 9 N ' 31631 W g /C -,/.3
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 existing well: .QYes or ThNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair Under#2I remarks section or on the back of this form. 23.Site diagram or additional well details: •
8.For GeoprobeMPT 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: r ,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 b 5 (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(0200'and 2®100) construction to the following:
10.Static water level below top of casing: Po (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: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r b 1-a ry above,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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /.5- Method of test: 4-1 r 24c.For Water Supply&InlectiontWells: In addition to sending the form to
�� the address(es) above, also submit one,copy of this form within 30 days of
13b.Disinfection type: C �-i 19 Y i VI Amount: I.l�s completion of well construction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016