GW1--06755_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1,Well Contr�actor9pInformadoll:
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Well Contractor Name FROM TO DESCRIPTION
°-�-'1 9 kY ft.
NC Well Coa Certification Number 7(S6,
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2.Well Construction Permit#: ` 0 1)4 1.) )._e.)- i FROM TO DIAMETER THICKNESS MATERIAI, : +
List all applicable well construction permits(Le UIC,County,State,Variance,etc.) ft. R. In.
3.Well Use(check well use): ft. ft. In.
I Water Supply WeIl: I=-lIMClEk1N h2_;i"441 r sly:w if,1 rrt:"s '.X: :.t,V-ri.Sc�¢r•`�: f`.,.�,�.: ,}.x,
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FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public .g, . it An.j
°Geothermal(Heating/Cooling Supply) (I/Residential Water Supply(single) 1 R ft In.
Olndustrial/Commercial °Residential Water Supply(shared) 1 ,+.,� yrilY,r k , r,� s.._,�. e,a• r .
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°Irrigation °Wells>100,000 GPD FROM TO MA EMPLACEMENT On&AMOUNT"
Non-Water Supply Well: 0 it 7„0 ft. y�is-e OUP
°Monitoring °Recovery R. ft.
Injection Well:
ft R.
°Aquifer Recharge °GroundwaterRemnediation ,,:
rafga1WAVILS +tt',l Milli bT s V f 4 .4* s,.WZ.17?�.."-;�.'-",greY S'ti
°A nifer storage anti Rernvery C]Ralinfty'Barrier t i 0M 124tnl
°Aquifer Test °Stormwater Drainage R,
°Experimental Technology °Subsidence Control R. it -
°Geothermal(Closed Loop) °Tracer p l; i('i tsc7aiidttliiy `a']i iktirecraaf e' ,=,<Veg. r-'r?r:;
°Geothermal(Heating/Cooling Return) °Other.(explain under#21 Remarks) FROM TO DESCRIPTION(color,hot dress,soil/rock slue,grataetr •
4.rDate Walks)Completed: I`P i''')3 Well ID# ' b R' �l)-0 it. eo(l tk roc K
5a.WeDtl ocatton: 120 ft. /4 0 It of'a f1 rk /OCR
Fes -tr beck-0 O It.
Facility/Owner Name
r Facility ID#(if applicable) it ft fr:-,: ..�, >H- :. _.,
oo Pa 1 5 r!it j cL r it ft v L.)
?Weal Address,City,and Zip I ft 't. O L 1
2 ` 2023
W 1c , (700 if is b 3 v
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County Parcel Identification No.(PIN) f?t_:r-.,;;--,.- ..a f�•.A
5b,Latitude and longitude in degrees/minutes/seconds or decimal der'eoae --- _
(ifiveR field,one Wong is sufficient) 22.Certailcatlon:
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6.Is(are)the well(s): Permanent or °Temporary Si of Certified Well Co for Date
By si g this fora,I hereby certify that thewell(s)was(were)consbucted in accordance with
7.Is this a repair to an existing well: °Yes or it Io 15A NCAC 02C.0100 or ISA NCAC 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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
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construction,only 1 OW I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dulled: 1 24.SUBMITTAL INSTRUCTIONS
( DI
9.Total well depth below land surface: (ft.)
For multiple wells list all depths(f 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: -O (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwate level is shove casing,use"+�' Information Processing Unit,16I7 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1��! (in,) t 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of tit:county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) a® Method of test: L160 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: k v\ Amount: 2/