GW1--06218_Well Construction - GW1_20230925

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: ' '
1..We11 Contractor rnforAm don:
Co� (ggNIL 1,•;W 'f `.4 .rl '`.'Mid+i •i 2F';;ira,.Wi-t.j,%r'{7.;t; -Y..K ,-r: ;,ram» '.+F 1 w
Well Con etorName FROM TO DESCRIPTION
age boa aSth ft. aAPm
74.ip as
NC Well Contactor CertificationN tuber i;.iCS;.btlGl R u _ R: — bl"e1 *cky' =�,�. ;G1r.V` 1°/` e_ 41i l RefhtFROM rTO . DL4t1ETER 2 SS MATERIAL{A (�iVCp. n, ft. in.
Company Name .:;4 rr
S
�i��`� ;tlt��1!II�Rr �',,�I�-+'fi333AYfaE(�`e'fftheriuisi'�lasedltiap�,s:i' .,-,'..�§�'t���. �4:r
2.Well Construction Permit#: L YN- 0'1(6 243°' .O�,) PROM y TO DIAMETER THICKNESS ' MATERIAL
List all applicable well construction permits(le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): _ it. ft. in.
'il+71$EFtEL''L'i A6 :C ig ig'i?rV'glga ~:.4 Sie 3lii ` ,i ?;:t'4441;:'.ir,P-f�)
Water,Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑AgriOultural OpAunicipa1/Public ft. . ft. in.
°Geothermal(Heating/Cooling Supply) 4Residential Water Supply(single) ft. ft, in.
Olndustrial/Commercial °Residential Water Supply(shared) ^ .n&:is[texiv ,.Y,: ..... ._ `" rb t ; i
°Irrigation D Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,
'Non-Water Supply Well: 0 ir. 2.4 it' in"lu Q ,�r•1 •
°Monitoring °Recovery ft. ft. V}'
Injection Well:
R. ft.
°Aquifer Recharge °Groundwater Remediation
',.atr,B,A>vf' PA4 +a 1) i'011ti a;z£7"'��cl av v s'�°}'lq, uC 4� ::
1G� �:. y
°Aquifer Storage and Recovery ❑Salinity Barrier , FROM i TO MATERIAL I EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage " it. .y
°• Experimental Technology ❑Subsidence Control l ft.'• :At.
F"•`Z l�lO' O (Att3ellidditIon`dl illee{?i; iitsSiiir.:� 1�Si,:.;ErS+ u., y i
^ ❑• Geothermal(Closed Loop) ClTracer for l
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION{color,hardness soft/rack type,grain airs etc.)
�
q��`/�✓1� D ft- W ft. &1 a
4.Date Well(s)Completed: 1 Well DMO it. 3'f o n' ,9 tai'l1 f G rock
f. ft. v
5a.Well/Location:r a
Facility/OwnerNatne, FacilitylD#('tfapplicable) ft' f F t;."il,,,�,`7''�i, '--Th L"11
4 eije,
Physical•A dress,City,and Zip
w a/c`- Ico$41 rt. ft. ��r 2 5 [OL.�
asy 7 'A,iv v4.,, ,,s�� x t `feoY' itirh.. 'YiG .
.:�E,�113}1�Kb,>_, .fix l!:s, ,�n�r xa`,.: �`� x- ^��..-3" t.._� ��o'.s ��
County Parcel Identification No.(PIN) ! MOI"OG
.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall Reid,.ne'tat/kaki s.s l Icioa;)
21.lrertincatioii: .i
.iv W ; oirt 3 -5- 26.Is(are)the well(s): lermanent or °Temporary Signature Certified Wellfek,tractor ' Date
By signing this form,Thereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or iilo 1SA NCAC 02C.0100 or 15A NCAC 02C1.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarla section or on the back of this form. 23.Site diagram or additional well details:
• Von.nu„ee the haelf(If title no ,provide additional well.construction-info
>s.Or tieoprobe/LWI'or Closed-Loop'.renusenn'u vveiisrav+pg.m same on to
construction,'only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add?See Over'in Remarks Box).You may aTho attach additional pages ifnecessary.
drilled: t 24:SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Stibntit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®20220'and 2®100)
10.Static water level below top of casing: r0"vanq ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft. Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11..Borehole diameter: cr/ (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(WC)
o,1..".. ..... 1414 Tesyr.Delotnr. yr 176on_1414
12.Well construction method: 4 t(' 41 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmentalhealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
1.�. Permit Program,1611 MSC,Raleigh;NC 27699-1611
i 13a.Yield(gpm) Method of test: D(A)�}
13b.Disinfection type: h4 I L Amount: I ► 1 y
Form QW-p riTortli'Ctroliria Depanment al-Environmental Quality-Division of WaterResources 'Revised 6-6 2O1 a