GW1--06702_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD (GW-1'1 For Internal Use Only: '
1.Well Contractor Information:
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FROM TO DESCRIPTION
Well Contractor Name : ° :
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NC Well Contractor Certification Number K
1513DTERCA$IIYO Cfot:.`iifiiitt-caieilfvri:llsj 011'IiNEA'(ff"aplilicab72) . �:'.,
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Company Name y :1164111 ER CAS .gOR�T.i}Ii1 G(geotber kma7 cliiiia:od'p'}' F�;�:g,:;•:�tv ri,Vi a t:
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.!ITC,County,State,Variance,etc.) ft. ft. 1 is
3.Well Use(check well use): ft' ft' in
:E7i<SCIiEEN i{5 ; °,_ ,_' ? Y'� ggt1-, `a: < 4c,,,i:'r:. °
-FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: i
❑Agricultural °Municipal/Public ft. ft. in.
`i
❑Geothermal((Heating/Cooling Supply) ❑Residential Water Supply(single) `
ft. ft in.
Olndustrial/Commercial °Residential Water Supply(shared) 1:8i.CitOl1T, .a i 1 1, l.,: ._ .. : .; + Y,,;
°Irrigation °Wells>100,000 GPD FROM TO MA r EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft' 2,10 ft' � ` �a Ira(0 f _
❑Monitoring ❑Recovery ft. f. )
Injection Well: 1
ft.
❑Aquifer Recharge °Groundwater Remediation t
':,1'9G /CatA M/x12.PC (Ifapiiikti le): ,s<:;' '"._w: . k_;.7. ,,t;- !, ;
°Aquifer Storage and Recovery °Salinity Barrier FROM I TO 1 MATERIAL I EMPLACEMENT METHOD
°Aquifer Test OStormwater Drainage ft. R t
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 'fit'ltlat ,1n1`GtO k(kf ach-kddiiioral-s'heet tfaeeessar)<j:'_, ..<.., ... , ,'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness eoWroek type grain size etc.) •
Q ��- 10 ft. ICI fta <17
4.Date Well(s)Completed: V— Well ID# 'Z,Q ft.ft. ,aQ®ft. ��Mf 1K
Sa.Well Loccaatiion: v"' ft
-Fe 1 r1 C.-1 h • It.. ft • ..... • `•' .
Facility/Owner Name
� ` Facility ID#(if applicable) ft ft.
3t I A °1(- PC lke.or SOY/ ft. . it. I .: c 02J
Physical Address,City,and Zip ft ft' I> • -,' `
i !. 'A.1::' l%'1 I{.*.S?, '"`' +-.?„�.�.'c.. :.r'v;:.!':�EY'.f .. �iiw..5} �,t',.g:ri"it/
Corra
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(1-w 2i fiiid,our.is Bong is suintirm) 22.Certiucallorr:
N W d 2 Z
6.Is(are)the well(s): Qiermanent or °Temporary Si of Certified Well ontractor D
By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Itilio . 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out latown well construction information and explain the nature of the of this record has been provided to the well owner:
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
$�pnr 1.;ennrnneri►r i or s;iuyeu-Louis veuiuerutui w'eu5 uavinu inc sainc
Ynu 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 (arid'See Over in Itemarlts liox).You may also attach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft.) Submit this OW-1 within 30 days of well completion per the following:
For multiple wells list ail depths if different(example-3@200'and AVOW)
10.Static water level below top of casing: (ft*) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+,,".
24b.,For Injection Wells:Copy to DWR,Underground Injection Control.(IUC)
11.Borehole diameter (in.) pregm,ra t( n'� MWT%P.air;ah N(!97(94_1 614
12,Well construction method: 41,trs r6 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie,auger,rotary,cable,direct pushy etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: /� g 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
W Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3� Method of test: 2.J�
13b.Disinfection type: 414, Amount:_4 _110
Form GW-1 North Carolina Department oI'l nvironmentai Quality-Division of Water Resources Revised 6-6-2018