GW1--06225_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '!
1.Well Contractorp Information:
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a'�1 S o© J ^t:1t4,AVAT;ER.?.0-XEs}. ..2 x I k O.OS<w g. ;.`, .: a5;W:R0.^: ,..
FROM TO DESCRIPTION
Well Contractor Name
r: : ft. Q ft. /C' '�'p r
r�'`'"� 1 ft. (ii 0 ft f; I
NC Well Contractor Certification Number ;1$OtJTI Rt�,ST[G(foriiiiacage ,"e s)O&:LINER a 1tceble)5'
e o P0k1 t - fikl
FROM f� TO DIAMETER THICKNESS MATERIAL
ft is �/C
Compaq Name:. _. t z,
��( (� '1 i.16i504 ER.CASIF(aORtIlliity,a(geuttiexuisFxiasedloop)r.= s ,,; .,t ;'. .:..as
2.Well Construction Permit#: Vv t' { t7� FROM TO DIAMETER , THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: "•1'1 SCREBNS A�.,.: :N . x}�'z.. g'l,2 _" * R �. `+ .�. l,;.s.�.f,y�
:FROM TO DIAMETER I 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑)vlunicipal/Public ft. ft. in.; i
OGeothermal(Heating/Cooling Supply) cResidential Water Supply(single) ft. ft. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) -i181 GI2OV , .,_r;) .' . t W,.....: ".,fir * r.': :
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. 2-0 ft. k tA"I v 1t (o v 1+P
❑Monitoring ❑Recovery ft. ft. , `l '16, J
Injection Well:
ft. ft. b Cl
❑Aquifer Recharge 0 Groundwater Remediation
19 SAo1I17G,Remt:j;v.'AC 'fitkitif iiCs ks ;._l ,r.l., •.W r; ..*s.s:1W
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM. TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft-' ft• ,
,. ❑Experimental Technology OSubsidence Control • ft. ft. •
OGeothermal(Closed Loop) OTracer ;2814DIZIIiLI NG 1 t3a(atfac7i'aitditioual iheets if ieeessary) % Y ;r;,> 4V,:
OGeothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solVrock type,gram slu etc) •
r0ft. to ft. Li.��r
4.Date Well(s)Completed: 1 -at Well ID# 9 0 ft. 16 4 ft. Sa i o o KC
5a.Well Locatio (O® ft. 1 0 ft. i r c a r c
ic
L.f,�{ AI(3. O ft. ft:
Facility/Owner Name( Facilfothva13
ID#(if applicable) fL ?"(,..11—.i\f F'' §
3 S 1 J i, / R lei?.. ft. ft: r 3 �}l � it � ft. ft. �Cf eti. C0�3
Physical( r Address,d` Ciptyy,and Zip
':~j21:rRE141ekRTCB om.:':t..N a,e4.m>*.im-:= * a s: r�C`, n..
County Parcel Identification No.(PIN) ' DV,/OA 00
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , ,
(if well field,one Iat/long is sufficient) 22.Cer' ea"On:
i
:N W a
"1/ : PI:IL
s: IPermanent or ❑Temporary Si Certified Well Con ctor I : - Date
the well 6.Is(are) ()
By signing this form,I hereby nib;that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1114o /SA NCAC 02C.0100 or 1SA NCAC 026.0200 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 will owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
<„_„_ You may use the back of this page!to provide additional well construction info
.8.For Geopron 1 i-or Cioee ded. p dicatetici mal ..ells having The same (add'See Over in Remarks Box).You may also attach additional pages if necessary.
conattnctiop,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1 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 all depths ifdffferent(example-3t 200'and 1®100')
10.Static water level below top of casing: '14 (ft,) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
?floater level is above caring,use"+"6 i '
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) ' Program 1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: a,' 10 l"ae.
24c.'For Water Supply and_Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpusb,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
lid Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ."2-I b
13b.Disinfection type: h..VI Amount: t trbv
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018