GW1--06732_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD(GW.. ) For Internal Use Only:
I..Weil Contractor Inforrr��mation g� t
�`v�®w 1 11 �l� 6''/0Vir�'IrS'DAMO;i]tar41 ' ;';.St7:.''�ik -`,S..Sih{i;:rr:'i^,'= °i t3>Mi n:i :4.1
:r
Well Contractor Name MOM TO ,DESCRIPTION
aa.,of A ft 2.1.® _ 24) j p
it ft
NC Well Contractor Certification Number 11 c
�tb �,��1 F./ �•A �QIV fa• Lao
, .fr Jrrr�l��.'4 .�y:.�r.ft. 1W.M DIAMETER V tt$� Ir'+f++f'i�It'.tf.''Jp MATE �M„Ma i..'�;'.
�!� FROM TO YlCA,�tE3'Fdt "1NiGHNBSS ��3rATE1tfAL
rit 1ti Iin. . ( $I tt vCompanyName `�,.
2.Well Construction Perndt#: Fe2:2 0 ® MOm TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t,e,U1C,County,State,Variance.etc) ft. ft, hi.
3.Well Use(check well use): e� n' in. •
Water>Snpply Well: •'•'Y f�� 1Y1�!lliClLTr�.q.. ,I�Fr*ih:�t-.Y:S'C iFM1/ •'b-..X M` N�� vSYi G`�'..Q�7�Pm c�"w"✓,-.
FROM TO DIAMETER SLOT SIZE THIC&vESS MATERIAi.
°Agricultural D1MunioipallPublia ft."r it. In
UGeothemlal(Heating/Cooling Supply) [BResidential Water Supply(single) ` ft. ft. In.a
Dlndustrial/Comtnercial °Residential Water Supply(snared) .,l.g,G'RooiT ;1 ,a`i,. ,. N ,-3 , r 4, , ,ii `
Dlrrigation CI Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT u
Non-Water Supply Well: b ft. to ft. hd r,d-o Na‘ j.bl`oiiii,1
OMonitoring DRecovery ft. ft.
Injection Well: it ft.
pAquifer Recharge DGroundwater Remediation ,}f;5, r.i tri-v me,k-< i'i:nnit iti e1 _6 L f r?i`? m5 x t7'4:s 17.
ClAquifer Storage and Recovery ❑Salinity Battier FROM To MATERIAL. ` EMPLACEMENTT METHOD
ClAquifer Test DStormwater Drainage t it ,ft. '
DExperimental Technology ❑Subsidence Control ft. ft. i
❑Geothermal(Closed Loop) OTracer ram'i it.It`17�t 'i 4at �addiilnnaittireteifneeb`sstiryli'�''>a s .r?*I„'- 'i-?:
DGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/reel;tsaa unto size,eta) f
� � 1�—Z� 0 0 t*1ea
4.Date Well(s)Completed: Well ID# (9I�ft. �.0 ft- S t i r O c.k
Se.i�%ell's,ue:itIon: :ft. ft. i
anif Bokri®(ar'') ft. ;, - ° .�.
Facility/Owned are c FaciliryID#(if applicable) it ft >
)4130 mdlein al. M il e.sch
1it ' ft. oil 3 ! toZ3
Physical Address,City,and Zip t R' Inf..);7.1::- ` Z:''r^•,`;^.t e:
AI6,S VI ,',,..,-;,,,,, ,.,,,q.d4.-,,-s r 4.~'Y ,'fiw. v°I .`.''s.,p.r=":'.o-h m....e"'i2`st.'44.1,". '1:f:;u'os
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well held,one lar/long is sufficient) 22. 1 iron:
—
6.Is(are)the well(s): QPermanent or OTemporary S c` '1 Vie• 'tractor f Date
By._ning this form,1 t.y certify that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or i to 15 NCAC 02C.0100 o ,-,by
NCAC 02C.0200 Well Construction Standards and that a copy
rib's is a repair,fill out known well construction information and explain the nature of the o this record has been`twirled to the well owner.
repair under#t21 remarks section or on the back of thts form.
23 5::.,aa..grara .ddit.'Grdl:;vl detaIIM
'.air.rrnprobelDP T or Closed Loop Geothermal Wells having the.sam ' 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. l9 ,t .SUBMITTAL IN3'1'itUCTIONS
F.Total well depth below land surface: 1 (f t') Submit this GW-1 within 30 days of well completion per the following:
Farrmultiple welts list all depths ifdifferent(example-3p200'and 2®100f)
10.Static water level below top of casing: 0 (fk) 24a. For All Wells: Resources
Original form to Division of Water (DWR),
�f9
if water level it above casing use"+J' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter (in:) £ •Poi inrc.uOli rr'cue,'- Py w Dv a, .uuvti6.vu..0_jwuv„wu+u,(,v
o Prngm,1636 MSC,Rateink NC 27699-I636
12.Well construction method: OL(r r e 1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc) county environmen= health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producln over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: �'®� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: I f Ill Amount 0I' I b