GW1--06207_Well Construction - GW1_20230925

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I''
L.Weu Contractor Information: ,
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v� i:attn.'I;SIt?2 Y:C,i.'ri`ry.ycv§.,�..r., li'ti're!N,,''L e 0�..� ,{�.S.`§�?-A*z, s ?,.�`. .ii...xi;:
FROM TO DESCRIPTION
Well Contractor Name
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NC Well Contractor Certification Number :05,;Q ER4,01NOlfot`}iiiittf a eDs t]RS It(tr'tiptillcable}; R 4.i,
I Ce, inwia 1 u ft. 1 viAmiSteti in i THIHICKNESJ MATERLii
Company Name
�i1 NistmpA311.;Cs m (aiiltlie taliCetaSE 460 4,Wrg
2.Well Construction Permit#: FROM TO DIAMETER ,THICKNESS ` MATERIAL '
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) ft. ft. hi.
3.Well Use(check well use): it. ft. in.
� iSCREBNO�;'4j4F• "'0,40' 1.L°f{;3,s.7t.!°y°yj;.�,.rc..FR i 5;,,?.,i`=.Cs.-rt' -.ti'.-Y^;
Water Supply Well: FROM 1 TO DIAMETER I SLOT SIZE1 THICKNESS (MATERIAL
❑Agricultural DMunicipal/Public n , ft. . in. ! j
OGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. it, ' in. ! r
Dlmdustrial/Commercial OResidential Water Supply(shared) ;1awittjul a... g .. - -gx
.
❑Irrigation DWells>100,000 GPD FROM TO MA .. EMPLACEMENT METHOD&AMOUNT ,
Non-Water Supply Well: 0 ft' 2.10 h• ,EaEa�+ fir.cr V t
❑Monitoring ❑Recovery ft. it.
Injection Well: ft. -
❑Aquifer Recharge ❑Groundwater Remediation ._ ,s,-t ,r,„ , x ,� ;
.;i'��aSz13:VA?Gite� aC�C{ii":aphlic:ilte� , t �.�..�.;s:_>�t.�,..•���,. a..,-� ,
OAquifer Storage and Recovery °Salinity Barrier ; FROM 'I TO I_MATERIAL_, T EMPLACEMENT METHOD.___ __
❑Aquifer Test ❑Stormwater Drainage D• 1
II1 xperimentai Technology ❑Subsidence Control it, ,.
- ❑Geothermal(Closed Loop) ❑Tracer 2b)111 1+10elit7G:f ael ddiilnnafslteets;ifnecessat x::- -Y.,('
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM PTO DESCRIPTION(color,hardness,soil/rock type grain slu eta)
.40
4.Date Well(s)Completed: -a " Well ID# ft- pro®ft rdte Kotk
Sa.Well Location: n' ft. 'ilJ
Facility/Owner Name Facility ID#(if applicable) ft- ft ' b L,r+•r I»i. `1. '���
3t(A4,600i-e. r.,_ So ft;`' IL SEP 2 52023 t
•Physical Address,City,and Zip f. ft
>�f��°_ 1 i� �;23t:RBt►2k1r�-,sip s.� 4<<r>��t��..�;.�� Lite ~ '.
�v,�;
Co ty Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
YL well field oaar,Iatiloa is a cicsa)
( s� 22.Certiircanon:
IC NV
6.Is(are)the well(s): t Iermanent or OTemporary Signature of Certified Well Contractor i, Date
By signing this form,I hereby certt fy that ihewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lli0 'SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well wnei:
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
s isr t.gnnrnfla/IiFre or hosed-loon Geothermal"Wells navies ilccaaetn+ ' "rDu may use the hack.of this page to provide additional well construed-on info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (mod'See Liver'm lceniarks box).You may also attach additional pages if necessary.
drilled: 1 24;SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: •(rt.)
For multiple wells list all depths"different(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (fti) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above ca ,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (tn.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
pro ram 1614 MSr.,Raleigh,NC 27699-1636
12.Well construction method: r6 24c.For Water Supply and Open L op Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3P Method of test: /d li Permit Program,1611 MSC,Raleigh,NC 27699-1611 •13b.Disinfection type: 41.31 Amount:_1/2-1.10
North Caroffna Department ofFnvironmentai i Division or water kesonrcesi Revised o-6-2010
Foam GW-1 P quality-