GW1--06730_Well Construction - GW1_20231024

t
WELL CONSTRUCTION RECORD(GW-1.1 For Internal Use Only: ' t
1.Well Contractor Information:
70,5 pp► y y�1 1 r q
0 h 1' 0 1 ti :19 0. ' 1 M.M'^_`+Z-':4k',,'�',�,t,?�`wit" :=` •la`•=?`s^x1 'ti n S:`.tZ4V•.t�`�7:`�131,M
Well Contractor Name FROM TO DESCRIPTION
�' ,1 9ft aS® roIP�
1t. ft. F
NC Well Contractor Certification Number s.• •. g E� Xtzt
�5 t3El"£ CeX$t!'ilo) ea $C:iY�Ib�YLI1V7sR'. zPli{s5TE1�a,s ...:lrsr:s,
�;t r , t ' P 67, nom a Dull THICItNNESS PIATi 3
V # IL 1 /1 i i
V R• 1m � f� 4tUlf - .
Company Name , ... .�.
�, I N('� lbx= ,,, a;-tit�t€ �`Iltt�`r ed• A'?il`os��tid}t�#>r ;"4 4a,�';�•.31" x
2.Well Construction Perndt#: 0 0[� �I 1 FROM TO DIAMETER `THICKNESS MATERIAL
List all applicable welt conatnvcion permits(i.e,UIC Counq,State,Variance.etc.) 1L ft, t In.
3.Well Use(check well use): ft. ft. in.
j Water Supply Well: t�o_�y. ,��*e�.s 5',4,.x xr t 'xt �y 4-Z. .:•,:art a3•x xF y{
�..' FYtwRTw"5'a4 � 2I
`+."�FKi v- ti'+'- e-;b ^-J"�'i�.�1 s•tt4t*2s'yK�.u.d �..ai7vF•»'• �4"...
f FROM TO DIAMETER SLOT SIZE TIUCKNESS MATERIAL
OAgrioutinrai El .icipal/Public g, .n, in.
°Geothermal(Heating/Cooling Supply). 1'''esidential Water Supply(single •)` h. R hi.
Dlndustdal/Connnereial °Residential Water Supply(shared) r r - A, ,
°Irrigation °Wells>100,000 GPD FROM T6 ATERw. . , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 �,0 it briedoviiv
°Monitoring °Recovery ft. it. 1
Injection Well:
fa it, i =
°Aquifer Recharge °Groundwater Remediatian � _ fit,,, y tr,•� z, ,
i.Siia p.Ja,lu Itaibl ,t a.�{c�'s+sr'Lii..1" d.�5ti1'iz- ai •'Rtm A
.• OAmiifer storage and Recovery © A,xg'Salinity Barrier , menu 9 Tn. I met, • t RIKPLAIITEMP TT WM-W %
°Aquifer Test DStormwaterDrainage. � It I: ' j
°Expetimental Technology °Subsidence Control s ft. ft.
UGeothenual(Closed Loop) °Tracer s,tl'•'i. i a 1 . ' 3tdd 1-:tt?s iiIM eets: ii atii .;`SAMv�,U gr; v
FROM TODESCRIPTION(color,hardness,sottiraek type,errata dee,etc)
°Geothermal(Heating/Cooling Return) °Outer(explain under#21 Remarks) O 'a
4.Date Well(s)Completed: t' 14 13 Well ID# l o b it Zd 1 1p r 1Ab Meek
Se.'WellLocat °nL+ to ;l� loDfr. -aGto n`' q r4/tif t' r )<
714 1• rem+ ctve _
Facility/Owner Mime Facility ID#(if applicable) R. ft. • ,:'.-,.
Physical Address,City,and Zip 64,(105 d. 1
P 00 40 i S�7
1�1 /1 C� Lt'�.'�s's� fe�4��`•YiC'!i+ioAog• j�,.z°.o '�',�•�t'���•,'S'"'•tir*tfi,,a''•'�' •t``t�,y,�j,+�.s
County Parcel IdentifcationNo.(PIN) ' D i. OG
Sb.g atltude and longitude in dcareeslminutes/seconds or dedmal degrees:
(-itara field,one'Wiens is siifuiszm° 22.C ' cation:
c .
/ N W If- 01-2-3
6.Is(are)the wef(s): iike.rmanent or °Temporary V Si o We Co for Date ,
signing this form,Thereby cur*that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or o SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy ,
f1his it a repair,fill out known well construction i9lfor/nation and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remark/section or on the back of this form. ,
23.Site diagram or additional well details:
B.Far caopi rbc./DPT or Closarl--Loop(eotherD9n1 Pin:'i..." its fitc.3o.7.s 'a Sit.uoY.uea iiic vatgi.va'uua uugiii‘ ',ivritiio auuiuVuui wcu wuauu.-3i inmo
conshuctiop only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Y Ui may also attach addi'danal pagesi7necessaty.
�f O 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CIL)
For multiple wells ltrt all depths(f different(example-9©200'and 2()a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: a.® ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water!evens above casing,are"+"�If Processing UnIt,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: _ (in l 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
- ...--- --- (�• r,....nm:loin Ni:31.;c3ieinni.,'a. 6%np.44.63'm
12.Well construction method: act-- ,.f CLOrl 24c.For Water Supplland(Then-Loop Geothermal Return Wells:Copy to the
(in.auger•.,rorary,cafe,directpusll,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produdng over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) �0 Method of test: Y 10 Permit 1'rogram,1611 MSC,Raleigh,NC 27 99-1611
13b.Disinfection type: ti 4h Aimount:_.____ l b