GW1--06174_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
L.Well Contractor Information: P
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FROM TO DESCRIPTION
Well Contractor Name
' 1 CI A 15®n '° i t°
NC Well Contractor Certification Number ; n rYF..N
1��5 Jt111al�i MOM �LnRtil��'fa��'ar'ss��it_ s3.l�l�l�V&R:��asi TO " DIAMETER THICITNESS �> . >f��.�.t�,RIAL —
El (Ced.Ai e 66 IC k 1 i di *; ()ILA P e,41
CompahyNeme 1 ft: ,� in. Q
^. ,,..y I ..g kk r�„164, I t?E I14Cttie aTiloisi do itIgliVIVI)li
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2.Well Coustrucdon Perndt#: ' - D®0 0 1 MOM TO DIAMETER. TRIMMER aMATsnlor,
List all applicable well construction permits(i.e.U1C,County,Stale,Variance,ete) ft. D. in.
3.Well Use(check well use): A,yfftt. ft. in. -
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t1.9' rani l}"} :4.':sell'''-4;r M>Svlt,�`'.�Y.�':M�,5w"k�,``` - �A,'c 1`5'!Strke r'* i.'* ,Y;:li
lWater supply Well: MOM TO DIAMETER SLOTSIZE THICKNESS MATERIAL.
t°Agricultural DIt(micipal/Public ft, ., .ft, , In
t.
°Geothermal(Heating/Cooing Supply) llliesidential Water Supply(single) '' ft. n,I in, r _
OTndustriallCounnercial Q12esidential Water Supply(shared) s- t t , ^^^
• [!irrigation °Wells>100,000 GPD MOM •TO . ,A'TrE�R-L�A,L,,; , E17i PLACL+MENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 2® � `'', Wjovriv
DMonitoring DRecovery ft. ft.
Injection Well: ft.
°Aquifer Recharge ❑Groundwater Remediation �,r I�r+n-
9 ND A4YWfeKlJdapplyYte)..e.A.1;NV,11 rt'i .,:g &41 „k .M '..
011.quifpr Storage.and R Prnvery ❑Salinity Barrier Fpnur 1 mn marmiAt. t imPt.Acrta m3T:L1R77mrtri
bAquiferTest . DStormwaterDrainage
DExperimental Technology °Subsidence Control . I.
DGeothermal(ClosedLoop) °Tracer 7 DR7t G tf 7tif7 {attsep si4tiToah#> tt'ri c�rssary7 ` r>:�'��:> .. .y..,:
MOM TO DFSai tonirorh type,grain she.etc)
OGeothermal(Heating/CoolingRettur'n) CIOther(explain under#21Remarks) tl 1� CRLPTLON'ai (color,hardne •
4.Date Well(s)Completed: t' I`4'.3 Well ID# to b it JeD i° 1a r ,Th trot;.
Se.Well Locatipn j . • t{>�1 . Z,OGtI. "aGO ft. A rik t if+ZI rO gjC
M 15 1 1-ea Vrlu&1 � fib' n` -
Facility/Owner Name Facility ID#(if applicable) ft. ft:
.(S1845 €lr €,1 S c a(A4 4� ft. _ _
ft. ft. �
Physical Addtass,City,and Zip L 11014
/ e9�./I;�7 `
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�c/A 00 1 0 1�( "';'AtvliFMA.4 e.Atf 'egt.-mil 4 t- g ,t,a q0, . vL s i'j<'��C'I :4.!' -2
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County Parcel Identification No.(PIN) DWOISOrri
5lr Ln tnrt. g I„ ,.in devreetiminntesleeermds nr decimal derees: t
(if well field,one latilongis gnaw* 22.C Wicklow
N W A ' 1 13
6.Is(are)the well(s): "Permanent or DTemporary Si ° • W Co ctor ; Date
signing this form,Thereby car*that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or d14 SANCAC 02C.0100 or 1SA NCAC 02C.0100 Well Construction Standards and that a copy
Jf this is a repair,fill out known well construction Information and explain the nature of the of this record has been provided to the well4owner.
repair under 1411 remarks section or on the back of this form.
23:Site diagram or additional well details:
S.For renprvba/DPT or ClosedLoop Geothermal cPS hn1^rg the ranc +v uar uav u+ Lack vr leeo im}v tv v Wv.:1-ztddi:icaral wells .cnct uct,n
constructio only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovef in Remarks Box).You may also attach additional pages if necessary.
drilled: g--/ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (B') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Vdiffe not(example-9©200'and Z®100)
10.Static water level below top of casing: a,® .,, 24a. For All Wells: Original form to Division of Water Resources (DWR),
( Infortllation Processing Unit, MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+•,., 1
nrehnla.rlomatar• tin_1 24b.For Inlection Wells:Copy to DWR,Underground Injection Control(IUC)
t'rn m4 t min 1vi5 ,,15;ciip, i::2,ii�. .a�,gwv r
12.Well construction method: a t r +�r/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(in.auger,rotary,cable,directpusli,etc:) county environmental health department of the county Where installed
FOR WATER SUPPLY WELLS ONLY: r 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)
hO Method of test: f` I® ap Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 11 4../.% Amount: i,Z. '-1 I