GW1--06699_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
JJ
r ?ob5�h\ k 14MA PER' LINES }, M'?'_ita ti, R. s , > x:x... i 4`
Well ContractorNae FROM TO DESCRIPTION
Name
I'e.l IA ft. 16, ft. 3 d i ffyi
ft. ft
NC Well Contractor Certificatio Number
'515 OU)<`L•'R G-AS2N>i(for=:multi-case'$'wells}'OR=L'INER(ifapplca6fe) ::3 ., 5c`,
' ka 5 FROM TO . DIAMETER THICKNESS MATERLIL
1 (/`- � ft 1° ft• 6 in.
n `dl C l VA n i e4 1
Company Name
0 ` f 16:=1Ni'lER'CASIIs(G R TEEBIN,fi((eot&et mal`efosed-loop)...,� `.>a,, ...' i.
2.Well Construction Permit#: `{ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): . ft. ft. in.
Water Supply Well:
;l7:SCREEIT ,, .r. 4'i �'W,:..:;:. k!�. %,.,5`✓.,.. .:.: x*r..:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Iylunicipal/Public ft. ft. in.
❑Geotliermal(Heating/Cooling Supply) CfResidential Water Supply(single) ft. ft. in.
_ ❑lndustrial/Commercial . ❑Residential Water Supply(shared)
.IB.;it:R20TJT..{?.:i .:?,.._,. .r`n;.;.. '_,1;.,...'nt. c,5a,.,,, s.i-, _ ir..Aq0 ; t;y:
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 0 ft. 'X 0 ft. bewfv i-8 j ri1 U f I-y -
❑Monitoring ❑Recovery ft. ft. //
Injection Well:
-
ft ft.
❑Aquifer Recharge 0 Groundwater Remediation
±:19:,i4AliD/GRA I/PACK-=(lfisplillciiblejaIVA.A'.Sr: . r Mg7.W. s AR ';rir:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO . MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.' ft. ,
❑Experimental Technology 0 Subsidence Control ft. ft.
0 Geothermal(Closed Loop) ❑Tracer aoa1I;;Tt,L2Natib (atcacbsc ditloaaliheets=it`neeessary):, ...`. - i, g' ?Z � t :
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
��-�3 0 ft. SO t'. Stott
4.Date Well(s)Completed:1 Well ID# if0 ft. Qp ft. j fQn e. roc .
5a.Well Location: ft. ft. r
Facility/Owner Name i p� I . r Facility ID#(if applicable) ® ft. ft. C'L 1 2 /• 2021
f! 1 !� 3i-watti, 1A t , LowlSicu,ri 1 l5 1 ft., ft. Ir`:,,, ... l'
Physical Address,City,and Zip � ft ft `� J' `
F4 h!c!Am 1� � - /q-o is/f z'1,1+fl ARKS`r 4. ,,j5,,,,:. .,"..1vr._:`;:.....:e,>r, ,.1:r.:rt m...z t.z v...`.- fS.vt d.im .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field;one lat/long is sufficient') 22: e I lion:
N W J4/747 7"at;�,. a3
6.Is(are)the well(s): termanent or ❑Temporary f Ce ' d ellV/jk
r Date y
By 'Wing this form,I here cent),that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or liNo IS NCAC 02C.0100 or ISA 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.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
e rer rveer.rehefr)PT nr rin.ad-T.nnn Geothermal Walla havinv.rhesnme - You may use the back 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 Box).You may also attach additional pages if necessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '200 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2®100')
10.Static water level below top of casing: ry ® ) 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 0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
I Program,1636 MSC,Raleigh,NC 27699-1636
12.Wellconstruction method: sir lint"7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
4p Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 30 pa Method of test: j-
id
13b.Disinfection type: °0 fray Amount: 112. tie)
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018