GW1--06708_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1 .
1.Well Contractor Information:
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Well Contractor Name
FROM TO DESCRIPTION sf ". z `>q: ,
-D-Ii `� A ft r2,0 ft I s5..�w�
n' , rt i , .
NC Well Contractor Certification Number . bri iip }: �gI& llehraJ6V wX ,
f c fiYigt sd`ts. < `
'I" ' ; FROM TO .. 7NAMETER TRICIINFSS punaIAI,
�, ar ®rods. Q ccu� ft. G n ln.
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Company Name � I � ,,... Q �• / �(F._..,, � � . m �z��.e>.,�.,' •
2.Well Construction Permit#: O 5 5 , FROM TO DIAMETER THICICNESS MATERUL
List all applicable well construction permits(Le.U1C,Count},State,Variance.etc) ft. ft. In
3.Well Use(check well use): fL ft. in.
Water Supply Well:
FROM TO DIAMETER_ SLOT SIZE TffiCI{�YESS MATEti1AL
~
OAgricultural unicipal/Public _ , ,„IL•, In.
°Geothermal(Tieating/Cooling Supply) residential Water Supply(single) ft. - it.j in._ft. f
OIndustrial/Commercial °Residential Water Supply(shared) r,,ag i r�.�•
e•+ui\dtiLy.tkm��..'r?+�A3., .Vr. 1 Yhy \oz V47rw vmr(`,.1.44 ls-e^}:.
°_,gation C7Wells>100,000 GPD FROM ,TO MATERIAL • MLA METHOD&AMOv er
Non-Water Supply Well: 0 it 20 n to sj ii% t l4 U
°Monitoring °Recovery ft. it i U
Injection Well: fL ft. i
°Aquifer Recharge ❑Groundwater Remediation
YirlOA P401 f a iapplli tihW c ";",s�-"*&15y.Lta6+Ei:;744:a 5 ai�S'.WV
QAttuiferStorage and Recovery °Salinity Barrier FROM 1 Tn f atrovn ei., rair r�rtmiATiraraaean
°Aquifer Test QStormwater Drainage .. .st.� ft.
°Experimental Technology °Subsidence Control ,, ft. ft. i ;
•
°Geothermal(Closed Loop) °Tracer -`4 i1t t7afat Vd 'c ageait ul¢bsaaer g--t4Z n :. R-,.
DGeothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM, TO DESCRIPTION(Mar.daraaa&,oturoetr tsae,dram eke.etc l
�1 ]'� b 1
0 ft
l�,i.1�//
4.Date Wel(s)Completed:t`n':). Well ID# 5'6 0 0 f b1(i) h, .-
Sa,,WellLocation: •.`aa :14 n` r1114e racfC
U oe firer nando.- , ,• t
Facility/Owner Name Facility ID#(if applicable) ft.
1 ft. u I.'t"�r g:::illV 9..e 0
3I2. Will rL1 1�Ukk Q. � 1i _ _ OCT ? ?2a
Physical Address, ,and Zip
Toll YiSt4U b1 at; fl :? p»3mm u Pro 3 `,ka'"•'''vlt L,s*ice .. lvt-s`.;
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or deein al degrees;
cif well` elh,one1attlong is nffulient) 22.Certification:
N W / `'9/ "`' -2 23
6.Is(are)the well(s): th ermanent or °Temporary Signature /. '.ed Well C Date
By sign,'thisform,'hereby certify that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Yes or 1014o 13A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Phis is a repair,fill out known well construction in formation and explain the nature of the ofthis record has been provided to the welt owner:
repair under ti21 remarks section or on the back of this form.
23.Site diagram or additional well details:
1• --:.:: -,- :_ ._.._..,i: ..a P:,:__yi_r,----1 -�--;
tf,tor'"¢enpro,im ur I'or Uosar2-Loop I COUI2rmni won:r.a✓mg runSwta6 •' •o ... .a ww v n 1v y .�... w+..aeavuw u.wwuU'. % �7tb
construction,only 1.GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Y'may also attach additional pages if necessary.
drilled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: kpio'amu@jo
) Submit this GW-1 within 30 days of well completion par the foltowing:
)
10.3tatic water level below top of easing: h® (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifxarer level Lv above easing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Co (in.) 24b.For Injection Weds:Copy to DWR,Underground Injection Control(TUC)
- .,:kmtm!!,i .71+Mtty P,aizi Ni..27u7 -.f.yy,L
12.Well construction method: Ct i r rot4 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:L 24d.Far Water Wells producing over 100 000 GPD:Copy to DWR,CCPt;UA
138.Yield(gpm) / Method of test: � '®� Permit Program,1611 MSC,Raleigh,INC 27699-1611
13b.Disinfection type: Ad—IN Amount: (l 2" 11
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