GW1--06731_Well Construction - GW1_20231024

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
I.Well Contractor Information: I
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PROM To DESCRIPTION
Well Co Name q A ft. !i40 ft, l5 m
NC Well Contractor Certification umber wl5 t 1 ���� ��i�� 6n :cQ , 1#� ttrCfiiriiMt�`eaie4:iizlls�i3ET3NOR�f�s»btia6Te�' s �v:,< £;.�.
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�ompClralkiLme1p ft. ��� 1t. ( In • r S 4$ /Oh f ,
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2.Well Construction Permit#: � a` OO 1 V 1 FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,County,Stale,Variance.etc.) ft. ft. in.
3.Well Use(check well use): fn ft. in.
1 Water Supply Well: f17.i 1?a; ° ,t1M, F ; ito x:i>4P:0>s• :rta r,1�" arc;'&?'4"eta!-I
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipaVPdb1ic It., n. .
°Geothermal(Heating/Cooling Supply) residential Water Supply(single) `` ft, ft. In. "
❑lndustriallConunercial Qsidential Water Supply(shared) Y.nh�
.IB1'A*+�1J.VTr ..y,.,.aY `4 e ; Y it t__li ::s_ai;t'J4` ,:Y;:=
❑Irrigation ❑Wells>100,000 GPI) FROM TO MATE ` - EMPLACEMENT MRTHOn AMOUIdT-
Non-Water Supply Well: Q f• 20 it. (� i, ra
r j t
❑Monitoring ❑Recovery ft. fG I
Injection Well: ft. it.
❑Aquifer Recharge ❑GroundwaterRemediation t ,�,, ._.,_,,•
4
•Siti AFNIVGR`A A'O'(if aTrpll i L l., l, li. N4i ;i--1'i :315 :.ti rP..
[Aquifer Storage and Rerrlvary OSalinity Barrier ion I. TO 1 vim—alter. t 7110+r.et171.s5nrr; munrl
,
❑Aquifer Test ❑Stormwater Drainage rt.
❑Experimental Technology ❑Subsidence Control ft.= it,
' ❑Geothermal(Closed Loop) ❑Tracer r-Itl:&D • Mg 'hi tditlueaigiiii; necb y1: :" 7.
D FROM TO
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) DESORPTION color,hardness,soft/rack type,grain doe,etc.)
Q o IL ft. �.pstei i
4.Date Well(s)Completed: v✓X1-a Well ID# act ft' /dolt <,)Q�
Sa.Well Location: a �00 a 110 IL q rri - ri 'k
l�r� ft. ft.
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Facility/Owner a Facility lD#(if applicable)
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®L35 tt‘l Ncl1 ft. ft. Iirr2 . 2O23T
Physical Address,CIO,and Zip •l 3 ft. ft. !n, ..,:n r -,.,
/�J pi, 5 ® ii' .A,k_ I#x 7.,i'�:T� i ;"{.t: k='^`�` tikes, :2(° £ r=•-4..p?..l"-e
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in decrees/minutes/seconds or decimal degrees: '
(dwell field,one'let/long is ra reien.) 22.Certileadom
ai. ,.. 3 _ D
6.Is(are)the well(s): liermanent or OTemporary Si_,.. ,.of Certified Well Contractor Date
By signing this form,I hereby cerify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yea or o ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out?morn well construction information and explain the nature of the ofthis 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:
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3.Vnr ticopronellSi'i or 1..41,,ec—..au1:uuatner ar re Errs"aving UM same
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: t 24,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells Mt all depths if dierent(example-9Q200'and 2Q100)
10.Static water level below top of casing: a. (ft•) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I10.Statiter c el is above casing,use top
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 4U (in.) i 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
a 1 r dtc V 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,directpush;etc) county environmental health department of e county where installed
FOR WATER SUPPLY WELLS ONLY: / 24d.For Water Wells producing over 100,000 GM:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: did Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: II+.k Amount: 4 I Y1 ,
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