GW1--06745_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD (GW-1.) For Internal Use Only: .
1.Well Contractor Information:
•ft S o n P eb 1'e- vC 1 a RV A. UViM iif Qo}' x
Well Contractor Name
FROM TO DESCRIPTION
� ft
-1 et A . '�0 ft, /0��04 -
ft. ft.
NC Well Contractor Certification Number
�Tv OtJTP;R:Cz"d'SIIY(+��fotyihu"'ift-CSSe11'iYtll"s):�1ftiI7i�ER%(IfaPPllcailey'�`..,.t;`�S x.�:
Cifacti P .bl.e., Veil r: t'u••4t) p ft. 71 ft. in. MaTERIAL
Company Name /
a�Ea7£�IPIFA�C:�[SF6t.G:�FlIt�2;t38Il�tfrfie8ih"m�i��los�:led+)~i ...�':;i��-�c�-;�;';�.'.:.�+`;;s
2.Well Construction Permit#:e> 1) -a . s(!r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction p is(l.e.UIC,Count),State,Variance,etc.) ft. ft. ►n-
3.Well Use(check well use): ft• ft. in
Water Supply Well: 'A111`.. LrT :0 4 i.r.f.`lg, ' .:�,:..? .�� :_'W �.r 1,'7 �"`_Z-
FROM TO DIAMETER SLOT SIZE _THICKNESS MATERIAL
❑Agricultural ❑ mcipal/Public ft. it. In.
❑Geothermal(Heating/Cooling Supply) esidential-Water Supply(single) fc R. in
❑Industrial/Commercial ❑Residential Water Supply(shared) i$. t ..:" S i _ _-4A ,,x, >,. }.,tit, x y v..l, Ai
Elimination ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: b fr. 'VD ft. brAjn r4 J I ►
❑Monitoring ❑Recovery ft. ft.
Infection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation ii/x _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To ( MATERIAL l EMPLACEMENT ETHOD
❑Aquifer Test ❑Stormwater Drainage ft. M
fG • ,
[Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer };o:1n11Ti1,'GSI+1G91idt btt"ac iadrhtivaat shietsfti ecesiti 'g a `4 su 04.. ;• Rw- '=
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,eoll/reck tyngprain stat,ceG)
�_ �,�3 Oft 60 ft.
C)ay 1
•
4.Date Well(s)Completed: Well ID# (20 ft. I g c ft. 5 e h( f rock-
ft Well Location: ' ft' - { ;
Facility/Owner Nanti ('' y Pacility-lD#'(if applicable) ft. fr. V L T
0 ( ( !'i"I5I c-7 IAa LOV% • 7f��
Physical Address,City,and Zip ft, tr'V1 +'D; i.Z. U'f
\M a■ ■ e A. ; 1.iltgl 1{lMAIM,4'`b" :, /Hligi/t3Z. e....r' aS7'Mi,4.•-z'�r",t?��,,...h�aY,,.,:
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n. I e
(iai`tctl tieidi,onc In i;o o,iw,vutrtcicnt) anon:
N w 3
6.Is(are)the well(s): Viermanent or ❑Temporary Si titre of C ed ll Contractor D
signing this form,I h reby cent'that the well(,)was(were)cons ed' accordance with
7.Is this a repair to an existing well: ❑Yes or lio . ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction St dards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner:
repair under l21 remarks section or on the back of this form. .
23.Site diagram or additional well details:
n 17. ev V..,r.a „zo Fl,.,1..,..1...E Val: tw r.,,,.:.a.::zd'.:::vual....dy--..- _
_- �:!•iee,SL!.'[•JS a•le •.aSl al:�.-:JVVI+c�e'ZU!'! fT x7iID i13V!?p.LJ v4XIU ____�.y -.........-�......w i...bv Y• .. .." wuouuwlVil
iisfo
construction,only 1 GW 1 is needed. indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).Yo u may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
q
9.Total well depth below land surface: I U 0 (ft.)
For multiple wells list all depths if different(example-3®200'and 2®100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7-0 (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"
11.Borehole diameter: 10 (In.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
�� Vgta a, 3 V MSCMSC,1\Plul�,U,NC,'4/Vll-1VJY
12.Well construction method: a 6fG 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: 24d.For Water Wells produchi?over 100.000 GPD:Copy to DWR,CCPCUA
O 14 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / _ Method of test:
13b.Disinfection type: A'f 1►� Amount: ' 1r l _ ,
FirmGW 1 North Carolina Department ofEtivironmental Quality.Division of Water Resources Revised6-62018