GW1--06222_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
L.Well Contractor Iniformation: •
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WellConhactorName FROM TO DESCRIPTION
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NC Well Contractor Certification Number ;SafiSTB�g;C Sm1G 1toerniIld el e)aR faNKlI(#'appicabli:) s „t:,At'
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CompanyName
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2.Well Construction Permit#: W 0 1 17J ` 1.0 FROM TO .DIAMETER TIUCI4NT.SS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) • tt ft. in.
3.Well Use(check well use): ft b' In.
v gOAOL..„ram.,,<.W--.1I Wa; `.v�.r•0;'`Pa ^g. tea.a}, i
Water supply Well: '.l4 SCt'f'`.n�3�s,FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
DAgricultural D unicipal/Public ft. ft. j in.L
°Geothermal(Heating/Cooling Supply) esidential Water Supply(single) '~l� ft z g, t in r
Olndustrial/Carnmereial °Residential Water Supply.(shared)• t-Xg, - E •rnt r': {' ti.:.,: } t. .. 's,; .
• °Irrigation °Wells>100,000 GPD FROM TO l MATERIAL _EMPLACEMENT METHOD&AMOUNT .
' Non-Water Supply Well: o it. 2-.O ft. tleA 1 ►t° i(Q,V I••7 ,
°Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
°Aquifer Recharge ❑Groundwater Remediation „ ,
::i9 �GRA` EX CIC flLaltplteabre� W Sti �,, ,. ,4• ti:.f.Y '
OAquifer Storage and Recovery °Salinity Barrier FROM TO I MATERIAL .. _1 EMPLACEMENT METHOD
• °Aquifer Test ❑Stormwater Drainage tr..,. ft.
°Experimental Technology OSubsidence Control •lc
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°Geothermal(Closed Loop) -OTtacer $1U.rDltTfs71l.6''IOG{attach'additiiiiii 5heei5,tfiiitessnr M " *gn";t.2;
FROM TO - DESCRIPTION(color hardness,iolUrock type,grain size,eta)
°Geothermal(Heating/Cooling Return) °Other(explaint under#21 Remarks) ft y�O it �i •
4.Date Well(s)Completed: Cu�(—q-'II Well ID# I®- 3 (to ft. �j'�,Q ft. G�l/'td,1G7-t- frock
5a.Well Location: Trt h 1 f f ` f f
a ./+ rasp 1"_ _ I ,.iy
ira5wel
Facili /Owner Name Facility ID#(if applicable) ft ft b
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'. $(#.11 - -(kl.foil p.. .\,. ..,„ „..,... . IL ,
ft 2023
Pbysital Address,City,and Zip 9q }}��,5�,,,>�py� . ���s �/y
w a���, I ( ate 319 3v.µ,�,.:e. n
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ r
(if well field,one let,ikng is Sufficient) ,
. a anon:i2 i
Wt�
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6.Is(are)the well(s): Ni Permanent or OTemporary store ofCeffitied ell Contractor D
By signing this form,I hereby certify that the well(s)was(were)conso ucted in accordance with
7.Is this a repair to an existing well: °Yes or i No !SA NCAC 02C.0100 or ISA NCAC 020.0200 Well Construction Standards and that a copy
If this is a repair,fell out known well construction information and explain the nature of the of this record has been provided to the welll owner
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
g„1Fnr kuntrnnivor r or Closed-Loop veuthermai Wells havine the same
• Yoo may lisp the hag*of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks.k$ox).'You may aiso.attach additional pages if necessary.
.drilled: I 24 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 '(ft.)
For multiple wells list all depths if different(example-3©200'and 2(a)1000 Submit this GW-1 within 30 days of well completion per the following:
water level below of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Staticuse top^ Information Processing Unit, MSC,Raleigh,NC 27699-1617
If water level is above aline,
11.Borehole diameter: c (itt.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Prc grz.,1E15 rgr,Patti;"1,,rvr/1 A90-1ti
12.Well construction method: 01`r- 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
..I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) V Method of test: 9RW
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13b.Disinfection type: 14 l''if\ Amount:
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r,,,,,rw-i North Carolina Denartment of environmental Duluth,-Division of water Resources Revised 55-6-2010