GW1--06749_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information'
i ' Pooke, t��''�`�{+;�?, ao:,,`-;tyip'f�.Er.''c kiK.t,f�Za.£Y-t�1F�..>3'.v�C.v..,r...Y. p t a?�t��ti'i�tt. t ..r....`�?•
We1lContractor Name FROM TO DESCRIPTION
_g_i q A- ft. ®® ft.
NC Well Con for Certification Number t t$;-j11 l ,g;41 0(ror iiii ih=leasiirvilogp 1 1:[if pj licablew : ti�.�_;�:
&f4.&i V00141
V f jy-g� �O FRo,N ft. * ft. DIAMETER• in. =CKNESRSS '.MATERIALCompany Name ( JV d / f a J 4 �/
�A� q - oal F : +?dirt x..ailloI.Sidr1`Ft {edtl iiiiA1Stictrfdp}� ,vrfi:,, t7.6I:'r , Au. ,<.
2.Well Construction Permit#: We Q 1 O 1 N 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. la.
Water Supply Well: a 7G•S'CILEl1N.- ,M :Fgi;"',:v w.'. � .;b.: r t.,;„ .w:': � e , _w_:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft ft. In. I
°Geothermal(Heating/Cooling Supply) esidential Water Supply sin le - 1 !!!
� P� 8 PP Y) � (single) ft. ft. la
❑lndustrial/Commercial °Residential Water Supply(shared) 4 .�, ` 4 . , -
�_iB't(IRt3`ti1'�_,.a�`i �,..:'�''-a _ ,s .x .t.,,.F.,.., a,.''. s. :.r a;:03u' ;-'�'�';,.
°Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMEN METBO &AMOUNT •
Non-Water Supply Well: ® it '2,O ft. ,MATERIAL
j f ,u t ' B
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation
OA fifer Storage'and Recovery ❑Salim Barrier Kati OtavlalrVt PJi Mi° abte -=0{ 0 AC �. ; 4'qu rY ty FROM I TO MATERIAL .-- EMPLACEMENT METHOD `
❑Aquifer Test OStormwater Drainage ft. Tt. s —
❑Experimental Technology ❑Subsidence Control ft. - ft.
❑Geothermal(Closed Loop) ❑Tracer 0411BIi:'[�tt�Jfx'lt,t ka thelfaddiitouaTittce i€rid esaa fl i aatWO �, 4E ;� >
°Geothermal(Heating/Cooling Return) ❑Other(explain under 1021 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain stze�eta)
0 ft. .To ft. ( c.d
4.Date Well(s)Completed: 1" 12 1'3 Well ID# so ft. 414® ft. !{4. 14.-1 j (IC,Jo,
ft. It. V ?
5a.,We le ,{t�� � -Location _ ,
i P 11 '[ . WI
q -ef J �� $,,,v_ ,ram k 4 Cx _ Z p 1
•
Facility/Owner Name ��a }� I Facility NC
(if applicable) 6 ft. ft. 0 CI 9 : 7 91-
1ti"tX Nu' �, . c ) f4.L LGilC'� 11,(26 t ft. ft.• :1 L AC
Physical Address,City,and Zip `fy� yry fL ft s:':,'- �•+"^°,o + ,�;
‘A��y rn{ 1S 6 �Qr �r.aa. �a^
L)�'&�� N YJ -:'.�.I':J J ,r i.0 y>" sN .:mod .i° ..ry; "'.y i''. og `+ +.v .+.- a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,am lataor.g is.saffiaten.t) 22.Certification:
N W ILli
-6.Is(are)the well(s): fglPermanent or ❑Temporary Sigaa Certified Well Connactr D
Bysi 'g this form,Thereby certg,that the well(s)was(were)constructed in accordance with
7.19 this a repair to an existing well: ❑Yes or ftiko ISA CAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards 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 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
Yol.ma;,,c,.the bask L , 4,. s4e to provide additio.� .t well -,.,ft,v°.fort info
e r L i. :'y•Ve s.!a t.=.s.:y.�M.�-_-!i: t ,,rJ:::,.j' tyly'Sit:4!!tt - -' •-.i-- : n.
.. .... - . -'SJt�•J�Y). Two- -.�
construction,only 1 GW-1 is needed.LIndicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: Ij 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 E/ (ft.) 1 '
For multiple wells list all depths fd�ere 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: 2 ) (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level above casing,use"+1
11.Borehole diameter: (in.) I 24b.For Infection Wells;Copy to DWR,Underground Injection Control(RUC)
prt,..^.,.163 „.SC n,.1-_t lire,,virnn 1 e2c
/W1-617
12.Well construction method: 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: /!(O((" Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: k 1 k Amount: I f'2_ (h
Form G$V-i NortuCaroima"Departwent at-Environmental Quality-Division ofWaterResources Revised 6-6-2018