GW1--06163_Well Construction - GW1_20230922

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Infor atio s
J 6t / / A.1/7 413�VATERN�S2W11 Yy
, }f 'aOl. V}{iY ,X �,e..i,Y;
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
l 3 A ft. ft. l ; .
NC W 1 Contractor Certification Number a r s j+ t'e` ^4
� .,1��QI!!l�iltA;BIIv�t(!y5'�mu1i)-e�ue"'divelli)iOR LyNERr(1f�Ap u�6Ye)h
t I, J l l 1� FROM TO DIAMETER THICKNESS MATERIAL
• Company Na �`Parry3
/ iS:INNER+�(PASINCTOM Y'Ii!ifikkabifeTiititleloyei)1640)c `r,045,^?aM4 ra,
2.Well Construction Permit#: ✓ 14 A3 — D )-O 1 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):
leISSCR).EligVAx +t_a�`-f? Ns Yrc+ASS11-M -4i4%x.1114. M:i m�a :a"._
• Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural • QMunicipal/Public ft. • ft. I, in.
Geothermal(Heating/Cooling Supply) gaResidential Water Supply(single) ft. ft. 1, In,
Industrial/Commercial. DResidential Water Supply(shared) ,4g1 O1t0IVT#Mikk?" :ti A s Ms kz. ` W=k s`ii"' 01
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMO
NT
Non-Water Supply Well: a
M D ft. �� 'ft. ,beAte_ ;te- /4�) z-s `�C a-r
onitoring `,ORedbvery' . - . - . - -- --ft.. .. - ft.. . . V
Injection Well: .fa ' ft. .
Aquifer Recharge OGroundwater Remediation ('frApp )`r R `
19:1SAlND`/ORA'VE1;=PACKt if `1lcatlle tax Loll✓-_a�.Mia,VA. f_.ic:x .N_
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test \1 DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft, ft. ',
Geothermal(Closed Loop) 'IIOTracer O,001:11'INCItiO'C?(a(tii'clita'd'ditiiiiin��ifiekiiiiibneb nhiliS) Mft,W4 s .
FROM TO DESCRIPTION
IO- �'Q N(color,hadnera,soli/rack/ type,grain elre,etc.)
Geothermal(Heating/Cooling RetuReturn) Other(explain under#21 Remarks) O (, ��if<• CG r I} ✓e! mix
4.DateWell(s)Completed: q"-So'-' , Well ID# 45 ft' 52),7 t' rA/'LI to
5a.Well Location: ft. . ft. `1, ! - •
vc-e- �D n-ey f-L-<.; it. ft. i rz 'R"a "`
Facility/Owner Name Facility ID#(if applicable) ft. ft. &14�'" 1.^-} V 0
/oo gal-cc)rt. Klt� e. Lot /3 ft. ft. i' . SEP 2023 •
Physical Address,City,and Zip ft. it 1 R
l `cRE n.G` F,v r. S .i;�l vttrrs-�-.75 i-g**.:54'*.#1.3K- -`
���i�P 11 :_.
isdtriZJG
County Parcel Identification No.(PIN) - 1:
I.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• •
(if well field,one 1at/long is sufficient) 22.Certification: i 3 7a5' 3 N 91, 9dI 6 6,c W 3 .
• 6.Is(are)the well(s) ermanent or UTemporary
Signature of Cert�ell Contractor . . Data
By signing this form,.I hereby certify that the well(s)was(were)constructed in accordance
w1th.ISA NC4C_t02C,#I00sor ISA NCAC Well Construction Standards and that a__-
- 7 is this s repair-to-an existing welt: ,` �'des -or= PIo =---•� _ � - 02C.0200�.
If this is a repair,fill out known well construction its ormation 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 Vase to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may1 also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multtple.wells list all depths ifdifferent(example-3 200'and 2®100' construction to the following:I ,
10.Static water level below top of casing:' 6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" . 1617 Mail Service Center,Raleigh,NC 27699-1617
li
11.Borehole diameter: to - (In.) I, 24b.For Infection Wells: hi addition to sending the form to the address in 24a
I.
above,also.submit one-copy Of'pis form within 30 days of completion of well
12.Well construction method:- r 1 f-r y construction to the following: I II
(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) I i"- Method of test: �/P ' 24c.For Water Supply&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: c...kl.Dr I n(° Amount: at C�- .s completion of well construction to the county health department of the county '
where constructed.
Form t3W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016