GW1--07640_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD(GW-1) ( For Internal Use Only:
1.Well Contractor Information: i
10L h f 6b k i5B Y�yi,�}{J�R VZ*,yt �yT``.ita .f'k'l� r.`i ,gycu°.r_.,:;'s!t�. ' - ,�,91P:; '.'%',1TS31-lir\.4Vi��+141: �1:.H..r i aS.,, f 7n S>
Well Contractor Natne FROM TO DESCRIPTION
�. ..., 1 A ft. IGa f<.Ji' q OM
ft. Gl i
NC Well Contractor CertificationNumber t .I A d :;-tcipr..;krs.t--iig Fr..,,,iitriL.., ,ireme)na x`n r scruff w , �;:.� - s •„y:•,:
g f NROM TO DIAMETER TffiCI{sNESS f L�MATLRL
�1�;1 ! 8�/� � ranil J"4 1 ® ft. I I (p 1 ft. 1 CV in' I a t D 1 i 4 V 1�ha I
�j 1:641NEWPON ORTUBLIGrialithiffui ikkINATIOop a wN* :,,(igi,,
2.Well Construction Permit#: � f (e.g. ✓ � FROM TO 5DUAMETER TAMENESS MATERIAL
List all applicable well construction permits 1Je UiC,County,State,Variance,etc.) ft, ft. in,
3.Well Use(check well use): ft ft In
I Water Supply Well: s irtREF;PI' .:4x .:_, f : - y t.�'!ti. ,lrtt,.trkiT�'.4ih. kM ?,',srr?.�+Fn1 10:1 h 1,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Iyllunicipal/Public it. I it I In. I !
I❑Geothermal(Heating/Cooling Supply) ' Residential Water Supply(single) ft, ft in.
i-1Tntinci ial/f nmmprrini flRPcirlPntial Water Snnnly fcharn111 _ -._,. ::.. •:..::.......,.,..:
❑Irrigation ❑Wells>100,000 GPD FROM TO J MATERIAL . , fEMPLA, , ;:Ms7•HOn&AMOUNT
Non-Water Supply Well: ® ft• 1 1 n harfbrilte, 5 p, i
°Monitoring ❑Recovery ft. ft. �`
I
Injection Well: -
ft. ft.
°Aquifer Recharge ❑Groundwater Reniediation
t%:f9 gsA W1,4"FtA%.te3%Wit#`atjpltthbbe)%i g4z:,/:'nthMO5 tr,! .,.s• �is',s.,.f.greia
t C1Arraifer StoraccandRecovery °Salinity Barrier lrunstiT 1 mn 1 MCTitnraV 1 cwIm anw•anv�smnvcmvnn l
I0AqUifer
Test °Stormwater Drainage l n ! ft. -—
r iEvr.orimantwl Torhnnlnnr r-1Cnheirlanra r,,,trni 1 ft. ftt,
❑Geothermal(Closed Loop) ❑Tracet 2b+ 1RIGT htittiE`n{Atta 'aili7ltFouit;lteetlfit 1�ee'eaiityY' r °*t�'��::r.s� �?+;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,so0/rock type,grain size,etc.)
ry 0 f<. 100% C I a. 1
4.Date Well(s)Completed: (0) al t 1 .3 Well ID# DO 15 o D• b rp O rb C.1G
55Well Iiocatign: i'. i ¢ i 5 oft• , 100 ft. 9 era Oftt`{,a r-i�
ia1eAV iVl' v8 ricettipj =. �,__ .: ;
Facility/0 Name ,J Faci itytD#(if applicable) ft. I( ft I l''1.,:� , _`:i, ''1 s:„ 1 •) 1
(al � i 20"
M®�' ai ckJ�ieb� ft
. Om , )1511 . ft
Physr• A ss, andp / ft. ft. r�r.r' �J
,'-7,-.:: -.)
s� broth
�ICI -2 W .G.'06:A...,?0g1 ife-Zi asti r -e r F'tsg:141,, ,ns1;74`
L..Y r:,2, Cv
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal decrees:
ts.well Lieu,Line Mt Lung is suusescny 22.Certification: ,
iv w f
0)219/Z;
6.Is(are)the well(s): 11 Permanent or °Temporary Signe o citified Well onttaotor Date
By s ing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or do ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction Information and explain the nature of the of this record has been provided to the well owner.
repair under#2I remarks section or on the back of this form. 1 •
23.Site diagram or additional well details:
on,only 1 d. I ate TOTALU NUMBER f ells (add'See Over'in Remarks Box).You may also attack additional pages if necessary.
construction,only 1 GW=1 is needed. Indicate NUMBER of wells
drilled: r 2.,eyrT, WrT L!NETIIIICm_Ibl'iS
9.Total well depth below land surface: a O 6 (ft.) _z s y `s
For multiple wells list all depths((different(example-3©200'and 1Ql00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: p (ft.) 24a. For All Well: Onginai form to Division of Water Resources (DWR),
Ifwater level Is above casing,use"+" Information Proses llg Unit,1617 MSC,Raleigh,NC 27699-1617
l(', I
11.Borehole diameter: (in.) \ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
fie.murex.mtnrv.rahle.direct nnch.etc.) _ ___ ..,i Y-_i.1-a.•_„_.._.._._r.L.._ _ti._im7 ..._ls..a
FOR WATER SUPPLY WELLS ONLY: ®� 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) C"' Method of test: os� Permit Program,1611 MSC,Raleigh;NC 27699-1611
�a
13b.Disinfection type: L r' '\ Amount: 1 J
I d . •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 6.6-2018