GW1--07642_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
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Well Contractor Name
FROM TO DESCRIPTION
,--.1 ft. Q ft. 9
f iin
ci �r Veil FRO,tit. TO DIAMETER THICKNES5.S ,MATERIAL
t acZii poolq. Ve i> P $ ft ft m Com an Name \/�• ® . 01- kJ.iQP Y „•16!:Il`tNER amii iiit�1F FB1Nise eai5er"m"sl:etased'lbopk lai
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2.Well Construction Permit#: � B � Ip � l� FROM TO DIAMETER THICKNESS ViATERIAI.
List all applicable well construction permits(i.e.UIC,Count,57ate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
n'l:;�SCitEt .ai=` .a-�le ✓ g .:n:iF•s^-s''�';f?:1;1•Z..b M 5 r A ll*:N^'d iefi:§ k::,a}a:
I Water Supply Well: — — I FROM I TO I DIAMETER I'SLOT SIZE 1 THICKNESS I MATERIAL
e- ...... 1 T..LI:- 1,T d....: :
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ;�,,, r , y , y:Y , �,,c,; x ,,1 .s .i -
;�cl$c..' t)LIT�..r,.v.xf. ,.x:_•.:s.; k�:S,..+..>"_'Uyf. .,;�..1,.�...�. �..v�,.iT.l.,`.�-�'.i,,. t._a,.�a,,:
❑Irrigation ❑Wells>100,000 GPD FROM TO MA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft �� tt. �� j �. � —
❑Monitoring ❑Recovery ft. ft. 7 — to �i�,i .J
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 6 �
]9•WikillY/P A:3 F.` M-A.r (iltiaigill abl ;erg;Mg5Wg jzi s- ; ._";`.r..,0 ..t
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control it. ft.
OGeothermal(Closed Loop) ❑Tracer 3Ai+DRiLI Ii±tCn'tif (atiachadditton ,slieiifti€necessat"g °K ,;; i,;.,'- ,myilwam
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO nEsclurrloly tcotor,hardness,sail/rock type,grain size,etc.)i 0 ft. �. ' + a i l
4.Date Well(s)Completed: I 1 � e Well ID# 1 ft. /0 ft 5ahots KL
5a.Well Location: [0 ft. 9,1+0 ft. 1;9c-. VI R. ,Y/�ti
rnp tt tt.• _
Facility/Owner m 1 A/ I Facility ID#(if applicable)- ft ft. s r ., ; �d `4-' '
1 0 9 P tne_. et.. Lo `^ 9 ft. ft.
Ph ical Address,City,and Zip ` ft. ft. ' nn l w;i
, 4:at -.n.s a' t�,x 3 .•y, t L y ,yYy'4 ,day,, - �rga hx p,•
Cif 11,CI I o.2i.;RP 2AI FS _Y.._l..,t.c - ,1:-6s, 3 a,1s.z x$ a a M Pac ._.`,C,h
11sr-"•• V •ti,J ,,J•J
County Parcel Identification No.(PIN)
(if well field,one lat/long is sufficient) v 22.Cer a ication:
6.Is(are)the well(s): drmanent or ❑Temporary Si;na ie of Certified Well Contractor Da
By signing this form,Ihereby certify that'the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 1SA NCAC 02C.0100 or 1SA 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 wl ll i wner:
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-Loop Geothermal Wells having the same " ""
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: q0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if derent(example-3(41200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ® (ft.) Information Processing Unit,1617 MSC,
SC,Raleigh,NC 27699-1617
If water level is above casing,use"+/"�
-. to „_'1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IJC)
rrogram,1o.01Vh1C.,.Kaieign,PO,- Io7,-iuJ0
12.Well construction method: CI 1 r r Ottrt 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
�n Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) g. Method of test: V V
13b.Disinfection type: 1#11-211 � IIAmount: a t
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! 1 Revised 6-6-2018