GW1--07641_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �, y ` y
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Well Contractor Name FROM TO DESCRIPTION
71 ft. 0oft. 9...3 r�M
i A fG ft. I ,
NC Well Contractor CettificationNumbetr
/� `p rn I .3 s'7 illgre Tl>tEEP-t`ANTI'if.`iigiiIiiiii cic't�w�lisl_r11R TRY6s:Stiiii_`gAfi.1» .<.�
C•i r 1>t tk t'ocir�/ 9l�!iti(i �+ ti g.V°" C '..FR.,. -:-:1:U.. (` DIAic;li'i;(t -THICKNESS '- MATERAL-. . .
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Company Name �� , "AlC) INtI C,' fitif,,kli.118I erikeoflieiiiilcloseaiiiiFletal , ax';�-:'s ..'�,.I:.
2.Well Construction Permit#: FROM , TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count;State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
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Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I❑Agricultural ❑b (anicipal/Public ft. I ft. I In. ` I
OGeothermal(Heating/Cooling Supply) rlra'Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) c18•eGROif'I sAs `s a e ,y s:*: i p 3z§3. �j•_`''^:0 ,.£:,Y F:e....:
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 7_0 ft. be v\` �t (AV a[J-`�l
OMonitoring ❑Recovery ft. ft. -1 ,, i S 1.6 (�
Injection Well: ft. ft. I
DAquifer Recharge OGroundwater Remediation � #
19rSorii,Gkt1vELP-ACK(iciti ea l.r- >._u.,., *T;
s
...... _..w-1,Y
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM i TO 1 MATF.RTAT. I FtitvT Ar 1iuvN'r MMFTcrnn
[ •
❑Aquifer Test ❑Stormwater Drainage • ft. ft.
❑Experimental Technology ❑Subsidence Control - ft. ft. ,
OGeothermal(Closed Loop) OTracer ' IliDAI 'ETNat tG.(atteati diffrili "sheei i'fnec ss3kyg'''t--,.- 1, f :ss t
FROM TO .DESCRIPTION(color,hardness,sei/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) i
I21 ft. 3c, ft. yak .
4.Date Well(s)Completed: 1 Well ID# .3„ft. a4 0 ft. 5 tt rkt/L�
5a.Well Location: l c tO ft. '[ob ft. mil•ra Vi 4 .. � od4,-.,_ -
Facili /Owns Nam; Facility ID/(if applicable) ft ft.
1 (3" q Li wy15 rt i >r n hi c ft ft. rat r 3023 .. ,.
Physical Address,City and Zip 2-11 4 Ql ft, ft. .".� ;'�'
���"� 1 I q' ?.'2�+: sf ik. ..i:.3.`,`:. �tkf:n1"hS'�7�...x";5'a,x•t��```.'4;�Y. 7:,""iis11:::. : .. .:.�.�.',`-.
l 1i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tli Well Imo,one leVlong Is 5ailliilwr.1
22.Certification: 1
N W L. 1r ll6.Is(are)the well(s): £Permanent or ❑Temporary Signa of Certified WeftdL
tractor I Da
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 1SA NCAC 02C.0100 or ISA NCAC 02CL.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 I ell owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well!details:
V....... .1.,,L....6..r ate:.. .
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW- is needed. Indicate TOTAL,NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth belo land surface: -[ Cl 0 (ft.)
For multiple wells list all dep s if different(example-3®200'and 2Qa 100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level bet w top of casing: 2-0 (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
I
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) .. . ,
12.Well construction method: ta I r 1,0 I 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ire,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: (( 6,�v�j 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: )0 1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: kf IA Amount: -Om l6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018