GW1--06175_Well Construction - GW1_20230922

I 2. , .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: . ._ :
L..We1l.Contractor liiformatro�p: "''
ba L9 { dY } Y A tiNWEY 4 N L.53J ah'ir4. l"
Well ConnnctorNa Name FROM TO DESCRIPTION
a-a lci A ft. la®f 2.4 i ds4M
ft, it. 1
NC Well Contractor Certification Number 1° .-,�w '`S�,S�ILTth,C�L gT 1`r.taLz."Siff ili�lts)QR' $A`:(i dig lel.`;F s•'?`, ,.,a+:
(j(� `Q� � � �1�!PP•• �/® FRoff 2 U 1)/A/tt:TER THICKNESS MATERIAL
= tr. l it 1n . i V �p a`V
CompamjNatnc 7 �! 7► „'1 1�1
+/ • 6I11C1AS11' kyl >i33lEltICSr('Ed ist;elosettuop�xkri was ?+:tzs;t:
2.Well Construction Perrnit#: b' • 00012.4 FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,Slag Variance.eta) ft. ft. In.
3.Well Use(check well use): m' n' is
Water Supply Well: MOM TO I DIAiMILTER II SLOT SIZE THICIO Ss ) MATERIAL
QAgticultaral OMunicipal/Piib?ic ft, it. 7n ,
[Geothermal(Heating/Cooling Supply) (Jesidential Water Supply(single)
ft: ft.i
In.• .
Olndustrial/Commerciai ©Residential Water Supply(shared)
°Irrigation °Wells>100,000 GPD F.FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: b n 1.® ft• b lid-h j'r�u r 5#
[Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
°AquiferRecharge ❑GroundwaterRemediation �, _
':lam Qbhifiien lrer•i;P_.Ecw_ iirimnaiahrgY r : k i3j_ a "::3.:?&ix td`F._tom,'•:
OAguifer Storage and Recovery °Salinity Barrier FROM i TO MATERIAL I EMPLACEMENT DIEIHOD
°Aquifer Test °Storatwater Drainage
It •
I:Experimental Technology ❑Subsidence Control Y; R ;
°Geothermal(Closed Loop) °Tracer ,20'SillEtaXINP7G{l(1da#lsa3iil#dihToiiaitieQt"s tfribc iiiiti ?• :" ? .;
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) MOM TO DESCRIPTION(color,Sardaas soil/r ck type,¢rain dze,etc) •
4.Date WeU(s)Completed: • Weil ID# ‘p n' '„ 14 0 n' S i'fed roe.k
It. R k C E_ p�if--I)
iri
)an i+ 1,oq 1.0 0 Lai ft -'t. { r
9 .w �, nn
Facility/Owner ame ( Facility ID#(if applicable) ft; •' f. S C t :r .+ N-LJ
49 3o M 4,[f 6n rc . M5 &sLL, t 1>n,�r fen Przx �,9 t)tA
Physical Address,
1{City!and Zip • fr. ft. ►a ;
At w_l ■ 1 3ia;1: •i' s`.:AiT c v. Y i ..vi c S.r a:r9-'�.i,
":2tV�28d4tr� #{Br*, .skSat�us::'$t4^t.3.. .N 1`h .�y}t✓«S�,+s. 2< Y�rl: 't. cn'?yc;
County ( Parcel Identification No.(PIN)
i
5b,Latitude and longitude In degrees/minutes/seconds or deeimial degrees: .1
(fwell held,one let/long is sufficient) 22 a t;.lion:
1 197 W l
6.Is(are)the well(si: 1/1"ermanent or °Temporary 8= I'r►, , t Date
By)suing this form,I e cart*that thewell(s)was(were)constructed in accordance with
7.Is this a repair tq an existing well: DYes or It t(0 15 NCAC 02C.0100 o/15A NCAC 02C.0200 Well Construction Standards and that a copy
.if this is a repair,jthl of t]mown well construction information and explain the nature of the o this record has been• • ided to the well owner.
repair under 421 rema,lcs section or on the back of this form.
71 cu.,d: n._... sa.+144 mal.unit tiata999:
S.For eoprahe/DiT or Closed Loop Geothermal Wells having the same ' You may use the back of this page to provide additional well construction info
construction,only 1 bW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over"in Remarks Box).You may also attach additional pages if necessary.
drilled: l 24,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - (ft.) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list ]depths Ifdii fermi(example-3@200'and.4100�
0 (iG) 24a. For All Wells: Original form to Division of Water Resources (DWR),
30.Static water level below top of casing:
limier ladle above sing,use"+� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1
2 :P-_':'--w--Il<,-n..,',_.-.,..DWP r.r.,. .•.,,...,..,A r.,:m.,.i..,c',,.,,.a trrrri
II.Borehole diameter: �:. In: .,. .. .._...... ........ ..:ro , ;. ---- ---- —.,-- - --- - •---.
(i ) Program,16361�tSC.Aaleidh;14C 27699-1636
12.Well construction method: 01/4e r' r 61.1 b
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push;etc') county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: f , 24d.For Water Wells prodaclnS overl 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: lb 1 Pit Program,1611 MSC,Raleigh,NC 2/699-161 l
13b.Disinfection type: / 4- n Amount:I 1' 1 b ,
Res."...a u,_i • fllr.rth.,'arnlina Ilpnrarern.m.n4,2...,:.v,n...n....,1 r,....,:..._Tw.:..:.._._cur_....be.....-..... •o.,.n,...a r c"'mat)