GW1--06226_Well Construction - GW1_20230925

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ..
1.Well Contractor information: '
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DESCRIPTIN
Well Contractor Name FROM 'OO itO -
'.1.1 1 A ft.
NC Well Contractor Certification Number • •N,15rtjilTtyttlC N4sapt; '` .' s) °l,'i1#EA:(ff•'b Ifc"abl€ ` n+.C '
( t.colti Paolo-o- Well r �a tll
nom Tri :max= TIIXCKN Ss ( .MATERIAL
.: �'
„ 0i. S.ft. 1QI 7'ATIO In. ! % I �4U!Y1iiri
company Name 16S ER:CA Offledtliei hilt se oop)s ' �5 e. r`•Al' �.n .xsstk.,
2.Well Construction Permit#: VIP '��- 5'1 FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. is
3.Well Use(check well use): it, it in.
I Water Supply Well: ArgSCREIN F}raw; UV.k. ,iatr"a`ViAr y-$ `a ;; ,w.kf ;iR k
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unrcipal/Public ft. ft, _ in.
°Geothermal(FleatinglCooling Supply) ltsidential Water Supply(single) 1
tt 1 fG� in.
❑Industrial/Commercial ❑Residential Water Supply(shared) J
'`�-bB.t�T;t)UT _%x .s,+rj. �' cr'z-..i.:�".'.'`�......!` §+:.' .t•..,;,� 3rf' ,.* v.o
❑Irrigation °Wells>100,000 GPD . FROM TO. MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1v ft bPN`}bbtk q f Clti I'
❑Monitoring ❑Recovery ft. it. �J
Injection Well:
it ft
❑Aquifer Recharge ❑Groundwater Remediation a
;I9::S'Al!TUVANC'f✓FA�iIE; .AplIC9bIaZ �?'+
❑Aquifer Storage and Recovery. ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMEN TMETHOD
❑Aquifer Test • ❑Stormwater Drainage -it it '
_ ❑Experimental Technology ❑Subsidence Control It..- it. .
iJGeothermal(Closed Loop) ❑Tracer 'aOSDIt11~;'L'ING tIG{attach'hddi8aiadlsheelsifikeesga fIH.<. ".;, S ;IS tc.
FROM TO DESCRIPTION(color hardness,sallhack type,grain size,eta)
❑Geothermal(Ileating/Cooling Return) ❑Other(explain under#21 Remarks) •�1 •
• • �3 it mot'b ft q l�'. (,,
4.Date Well(s)Completed: Well ID# 10 ft' . • ` ('d/�►�kG f af,�l�+
5a.Well Location: ft it
•
Fa ity/Owner Name Facility ID#(if applicable) ft' f G � ¢ .•
�
' �A4 fish +. ���� ft ft. SEP ' .r1 ?)23 {
Physical Address,City,and Zip • • it ft. l 11 ^
Q { e/n (sZ1r L'Ii A lfSf :.•1 i x.._ sk �. . ..�... ' !c
, vrv�l"3i•)kri
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iiweil field;i,ai l wrlong is.ssfaiciarut) 22. c In i
X W i . I,.. /
6.Is(are)the well(s): lermanent or °Temporary Si f Cert' ed We C ctor , Data
1.
signing this form,'hereby ertsJ'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Elio SA NCAC 02C.0100 or 1SA 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 ill!owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well detaiils:
_ Vnn may rzew the hark of tienaaa to nrnvirie aclriitinnal well nonctmMinn info
an. or e_ve�aprabets►xa or Ciuso!!-aftw&contorttn2Ar Wells niivrni,me Srmn
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over`in Remarks Box).You may also attach additional pages ifnt:cessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: #3 �® (ft) Submit this GW-i within 30 days of well completion per the following:
For multiple wells list all depths if digerent(example-3®200'and 2®100�
10.Static water level below top of casing: a 0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use" Information-Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Z]y- t c2c Aden u..1..t. NO 47500 1424
12.Well construction method: air f 4 it 24c.For Water Supply and Open'Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,et.) couhty environmental health department of the county Where"installed
FOR WATER SUPPLY WELLS ONLY: 1.
24d.For Water Wells producing over 1001000 GPD:Copy to DWR,CCPCUA
Permit Program,I611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)
r 0 Method of test
13b.Disinfection type: ' Amount: 2.)117(010
k 1
Form OW-I North Carolina DepartmentoI'Envimnwental ouaaity.Divieinn ofWaterResourcee; IUevised6-6=20IS