GW1--06754_Well Construction - GW1_20231023

WELL CONSTRUCTION.RECORD(GW-1) For Internal Use Only: '
1.Well° Contractor Information:
1 to e 1 ;Y r. + �".�1;`•'•� .!f S s.L;fiE;.t_..a�'•S�* '4. °n'?li' .�`.•'''�A,*'} t.
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Well Conaactar Name FROM TO DESCtIPTIONs
tail A ft. I"A0 ft. CS 9 pirr
ft. ft.
NC Well Contractor Certification umber „O5i fsrfi.'1S'R?• ,411�I (ior;ft4ligx .vfills]:t]I ti�;A`(ttalir_fll'cebi6i" ,, ,VM hl•-�4
C10-1t1tihi y\ P'`!Al��' t,O`•• `FR�oymi1 TO f4 DLL{,LTER tn. =Cs}G�}ItSS MATErYiLCompao3,Name G �° I ®� cd!,V%l�f
•' ?Y�fOf IRE II I eurrigiral loci g4MVPAgi-
2.Well Construction Permit#: W — I 0 rb J 14 5 9 FROM TO DIAMETER TB CICNESS MATERIAL.
List all applicable well construction permits tie,UIC,Count,State,Variance,etc) it• ft. i Ia.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: U zB�."4a ii'•:74i'';l t' - ';5u}vt.`xifcrfi,I "Ywjetir4 %, r s''s'F • H:
FROM TO DIAMETER ` SLOT SIZE Mat: SS MATERIAL
oAgricuitural 0 ,.'cipal/Public p, , •O,.- .In.
OGeotheunal(Heating/Cooling Supply) ��.' -:idential Water Supply(single) r�
ft. ft. hi._ .
Olndustrial/Comtnercial OResidential Water Supply(shared) T .e
g „ R� �� 'a ..i4 Y .�i.L','.�-t.}L..,., �}'......L :3�'i.�'Yj:• .•1.''.•:s:,144::e::l:.F,dt•"Y..i�+`&`�:i
Olrrigation • DWells>100,000 GPD FROM TO MATERIAL EA PLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 it. ao R. I, *o�ntf ei you ity
DMonitoting ORecovery it. ft.
Infection Well:
it. ft.
OAquife r Recharge ❑Groundwater Remediation fn �y�9�a�(�tmr+p} -z � use„ n.ya
t� �+ tiisk1' 1,61te��'1+C�7+s7WIeit b- 3�.`lq.`fc i,',;.e i i i .a•V<I:y .7
DAgtiifer Storage and Recovery 0Sahnity Barrier !pew ' To 1 MATFbTeI. ± FMP7 9�Rn asm 7lesmvnn
OAquiferTest. OStormwaterDrainage it. R. "- —
DExperimental Technology OSubsidence Control it. it.
OGeothermal(Closed Loop) OTracer 00`ttid ti sitd ibai2diiiibi b7icet"s`•ft:ne"r itiny:SC 'L:'gslx�'k` t t"t'iN
❑Geothermal(Heating/Cooling R DOther(explain under#21 Remarks) FROM TO DESCRIPTION(cekr,hardoesr,�oWroek type,�atn atze,eta) •
11 2,3 0 ft. i® c.1.a
4.Date Wells)Completed: Well lD# 4 ,�j lw ' r C C K
Se.WeULocation: . ) [to iw . 1'10 i:: or reunite, ra e J<
Facility/0mmName Facility ID#(if plicable) R' ft. i-, T f t -i
.i( 4)1d 5 Tc� (r' + k1 . 'I 03 • .: �, a �..
it ft.
Physical Address,City,and Zip
it. ft. 4�T LGc3
ktl j4 k e-- r ti Trig tt=t'Sa i aa... i iitc,a . .: .45,:J ii:F•{ :�As?t r:; z;tin
County Parcel Identification No.(PIN) G
Sba Lattude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lallonZ is suflicieu'). 22.Ce a le! s sr
N W t, i C, �1c qfsy
6.Is(are)the well(s): permanent or OTemporary Signature ofCertifted ell Contractor Date
Bysiwning this form,Thereby certify that thewell(s)was(were)constructed in accordance with
7.is this a repair to an existing well: DYes or 0 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
Iflids Ls a repair,jlll out known well construction Information and explain the nature ofthe of this 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:
I.l nI ii•fpw VUelarl or:,.toJa:'.-•LCnp b tnrc ai ii!a:Ii Liue`ifl no..zza V " IfSJi ltv f.lflC-LlOt"V _.- 41flv_;ile l!LVYe -6-e--iliticAval wril lil•L1t iL-t".mi1ri!.1
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 q b (ft,) 1
For multiple wells list all depths tf dii fe ent(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: /D (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwatw level is above casting use"+' information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in)- 24b.For Infection Weiss:Copy to DWR,Underground Injection Control MC)
12.Well construction method: a I rb ek p 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: Li-DW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: h+h Amount:,.. 2-