GW1--06221_Well Construction - GW1_20230925

,L:.CONSTR.UCTION RECORD(GW-1) ::For Internal Use Only:. ' '
Nell Contractor Tnformad 6on: '
FROM TO DESCRIPTION
Well Contractor Name tL aD it ts l4I
� ft. ft •111 .
NC Well Contractor Certification umber 05 ;f aSIISU(fb ? li[r iv§aas)i>1 `tie=3P 1R er1 �. k s;l
, PROM TO DIAMETER THICKNESS MATERIAL
Ci�' � .'� �� 1� Pl/e t � b ft, 17 >i, J in: �o- ilk 4'1Vill/t
Company Name "i "' t a.. 5, •aa
7 ;' '�v'�Q l'ltc Cri# oiiu: cl eYoiilY)<;�; -.4.,I xtiIAII }
j I rj 1.� J . PI,'��) FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ��` is
List all applicable well construction permits(i e.UIC,Comm),State,Variance,etc) ft. ft.
3.Well Use(check well use): rift' ft' hi s7 ?»
I Water Supply Well: MOCIt tt, A�'Yi' Vigt t tw 3 t'Z'Aiti-F,z�4'v v?�i ''",4 4 r S +is4e.,�9 ns l"'-k"'0d a.''
1 TO 1 DIAMETER SLOT SIZE Th CKNESS MATERIAL
r OAgricultural ❑ ' cipal/Putilic �` 0, it 1 ia.
°Geothermal(Heating/Cooling Supply) �idential Water Supply(single) '" ft. it_1 In. `
❑Industrial/Commercial ❑Residential Water Supply(shared).- r y . , , r;igv 5, r
���$�isi�0`il'L'�.�,-s`�.c.�:.st�`.. _c�?�n� ..=�.r��?��::t,.��,xxd",,..� �-:n=1;:<....P.•�"�` -�.'fy;
❑Irrigation .':.DWells>100,000 GPD $
FROM TO _ MATERIAL EMPLACEMENT
Non-Water Supply Well: 0 ft' ao ft: hero-mite) ciftig i` f'
©Monitoring ❑Recovery ft. ft.
Infection Well: ft. ft.
❑Aeq^uifer Recharge ❑Groundwater Repudiation t 11:Ee Au'rA b^fJ raS1at:'.ltku f,Trif hifii tAllitaFv:M...ig.66j.x :+`+ ».....K.i ., _`aYAiZel.
❑Aquifer Storage and Recovery ❑Salinity Barrier ;axoM.. To. c"i) MATERIAL__. - _ ...l EMPLACEMENT METHOD
°Aquifer.TestDrainage `R'
°Stormwater
°Experimental Technology °Subsidence Control , it -
OGeothetmal(Closed Loop) °Tracer t i` I 7s" ati3cl ddhlona dill ii sa 'r: zt :%=,»•V,
❑Geothenual(Heating/Cooling R ❑Other(explain under#21 Remarks) FROM TO ' DESCRIPTION(coior.hardness.son/rock tape,ai�ta she,etc.)
® /5® �1a,
9 Pi 4.Date Well(s)Completed: �v Well DMIS® tr. d r i 0 n i rdw ill (0 c K
5a.WeULOeatton: �rl r j:it A ft. /14fi� a 1''1i b►-a<ce. errsr.
(
1
G tl O r dy7. T. q
P ility/ amer Name r i 1 Facility ID#(if pplieebie) f �`'�L L:¢� t h j s.
Physical Address,City,and Zip y.a
V.)it 7�P� a:;Gi '��`:�-'$'ioi, au„�Fx"."��?ohAvm���'h"+•u,5'7?�.:��r°r$`?'.-:''-lam.-J'T_
V v':t
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if wen field,one lathong is sufficient) 22.C tilde n: , .„--) :../..—..., . _ ,., 1 ii i _
6.Is(are)the well(s): permanent or ❑Temporary Signature of Certified ell Contractor! Date
fly signing this form,:hereby cernfy that,the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o !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 owner
reaair under#21 remarks section or on the back of this form. nn _
or.-.err_____._ _a.n,a,.-ci "ep,det=gils:
R.Ea-Camsr.alleM T or Closed-Loop Centherrunl Wells hn inn the same . You may use the back of this page to provide additirma.weil enitctnictinrt ilea
construction;only I GW 1 is needed Indicate TOTAL NUMBER of wells ( . e tSe Over'in Remarks Box).You may also attach additional ga pis if necessary.
drilled: 1 24:SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 14 d (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths"dierent(example-3@200'and 2®100)
10.Static water level below top of casing: 10 (f ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" ;
a-_,-_u__a=er_n-. r+-_-.�^riwo, rr«dn...nnnnA rt.ritnn rnnbnf tlr�rn
11.Borehole diameter: {in:) 2 n:,r V: ller,ebuverr .r uuu. y, -. -- -.-
Prngratn.t 616 MSC,Raleigh,4627699-14?6
12.Well construction method: a 6 r lra-4r? 24c.For Water Supply and Ope[L'oop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department ent of the county where installed
•. FOR WATER SUPPLY WELLS ONLY: B ` 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
P b vv Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) 11�y1. 9ir� Method of test: pr i
tab_Disinfection type: _!► Y r a „ Amount: 2' 9 4