GW1--07145_Well Construction - GW1_20231101

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Co tractor Inform lion:
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(F4.x LI r'� ' I,TER rIE$S�i1r `?`'rkt;'�CS`"rti�`. ice,:z 3 ' '.C;3s'Y�t 1 f n
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FROM TO DESCRIPTION
Well Contractor
Name'[ �j ft. f'
liJ ! 5A ft. ft. H
• NC ell Contractor Certification Number ^ :15;p1!lFER CASI[VCyJ(fot�xmula caredTiv llh)"UB IrTIV>rlt.(if?np lltrAble) '': :"
041)� ( �.! I� FROM TO DIAMETER THICKNESS MATERIAL
lam(/// l 1Y iTru-, I J.5I h 4,'?.(in. DAzt p vc
Company me / ;:.d40YNNERICASIM6r1016 IIV'Gi(I;euthlii" ididfi led=liffili esrt,Ir O 07•iilrid
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2.Well Construction Permit#: 5 3` 1)(9/4- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
ft. ft. in.
3.Well Use(check well use):
0110SCREEN 'Ifni,!•Y".•AW '0 sl ,' Oi r",:,?;',it -.:,;;W:i :�??n".,a�iz a aitik.Ytss3
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft, ' In.
Industrial/Commercial ; ['Residential Water Supply(shared) ;Y'e ntou :; 4o's,:; 11 ''0;'{•' 1 y"`1' AI-m `' i '}it ; "`Z
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply !Well: P ft. ft. b e gini�-� I T:i_ hoe_rD tom- zi
Monitoring — ['Recovery --- -- - ft. ft. / -
Injection Well: ft. ft.
Aquifer Recharge ['Groundwater Remediation s, ,, .
ri9.'SAND/GRKVEI:PAC1d(if{applibatile`iti AE.tla,"1"z000i ns J fi`tik,., _:.":'
Aquifer Storage and Recovery' ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test • \: `. DStomrwater Drainage ft. ft.
Experimental Technology , ['Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer q20 bR1f .+t�IO, OG;(at(ach*dditiona s11eatitifiiecesiiiii)'i r?>'�. =i;5
FROM TO DESCRIPTION(cater,bullpen,stake&type,grain etc,etc.)
Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) f
o ft. /A4 fb dirt cla.y
4.Date Well(s)Completed: I/5'-�-/ -�J Well ID# .5‘ft' ,g.5'ft. ( rQ hi t�
` ft. ft. C./
5a.Well Locatio l
�-` 1 1 a- .� ft
1 1?- . ft. 'a ~ _
Facility/Owner Name Facility ID#(if applicable)
167 ver tt)ao I �J y.�, 1 Y r t? b .. ft. NOV 1 7(�?3
4-
Physical Address,City,and Zip .ouRE����ft. ft. 1f1, r 1
MC DOt o J f 1ld d dg 0 �� aCe
' County Parcel Identification No.(PIN) _ -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certification:
35: 7( q'3I N ''' g51egli6'7 w fle" /D ,1-�.3
6.Is(are)thewell(s)aPermanent or ['Temporary
Signature of Certified Well Contactor -[� Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ['Yes or INo - with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Wetl Construction Standards and thata
If this is a repair,fill out known well construction information and explain the nature of the copy 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:
8.For Geoprobe/DPT or Closed-Lapp'Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed.Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
• drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5" (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple.wells list all depths((different(example-3®200'and 2©100) construction to the following: I
10.Static water level below top of casing: ' .M (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"++" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (O (in.) 24b.For Injection Wells: In!addition to sending the form to the address in 24a
• above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: V a I £ -Y'V construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.) /
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service Center,Raleigh,NC 27699-1636
I
413a.Yield(gpm) Method of test: AI r 24c.For Water Supply&Infection Wells: In addition to sending the form to
1 ‘ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C I j I) i n r, Amount: , (iG completion of well construction to the county health department of the county
/ where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016