GW1--07872_Well Construction - GW1_20231205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:Pe3eA,
i/ ,.54,`,WA•T,F.1ttZ151VES'fim x,?www.%v>?':i�k�?=esom.m m:3J7esgsm
FROM TO DESCRIPTION
Well Contractor Name
-�.11 A ft. l&e ft• d rrA di rtz i Gk b i-r
A ft. ft.
Ci f'!i Pot 5 fie.✓ kVv 7 u tVa�yuuaIAMETER THICKNESS
YY e(� FROM TO DIAMETER THICKNESS MATEtRIIA(L
0 ft 51 ft in t !iii a/Vih/17r
Company Name i �. r1
i� ,16 sXNNER'.BASIN. 2OitiiTIFSI e•1 lai fiefmataiiiedAiiii . Z,Tf u a g,T
2.Well Construction Permit#: �--"8 f 3 115.)( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(IIC,County,State,Variance,etc.) • ft. ft. in:
3.Well Use(check well use): ft, ft. in.
�I1:',SCRREEN'.,t»; .s ta:... ua:e. -.;, `'.I.,:.in`t2 1.:5 xc t.„rv,4 i t„': ti'
I Water Supply Well: I FROM TO DIAMETER SLOT SIZE ! THICKNESS ! MATERIAL
❑Geothermal (Heating/Cooling Supply) esidential Water Supply(single) ft ft [
in. I
❑Industrial/Commercial ❑Residential Water Supply(shared) F1$.GROIPI asp: ..r �.3�.1+ ,. -.:�`* 3'�1a k
❑In'lgation ❑Wells>100,000 GPD FROM TO —MATE --r-EMPLACEMENT'METHOD&AMOUNT
Non-Water Supply Well: 0 ft, ' o ft en r`� r a V i t7
❑Monitoring ❑Recovery ft.' ft.
Infection Well: ft. ft
['Aquifer Recharge ❑Groundwater Remediation , r k �
_ f�-�^AND/Gli.4'f??E.p R (if-ajpIEcalsfe) 3�._.::3 ,�':.- �.. .x_ ,;.._, ,...,,,
i_-:�.K::......,.,„:.g.,“,,....:1,...-,,..,.-... .�'-4._..:��:...:..:.:. ♦a\V.,1 - .., ..a..a ... ...,.....-.......,..............v,.
❑Aquifer Test ❑Stormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft. ft ; A
❑Geothermal(Closed Loop) ❑Tracer 0:(nISIL7iING`I OGratfafkiddittonacs'h¢etstitt'rnecesr:ar':yM_. ,.3w a" r s= f
FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Re ) ❑Other(explain under#21 Remarks) D ft. tJ�f' ft. S
464
4.Date Well(s)Completed: 1 i 17 Well ID# ft. lot ft. �� �-� r G
i ft ft. �J
5n.Well T.ncatinn,
• �i _ti) ft. . .-.._.._ _ .r_>q
L-111 t C1 r<o 1,-- g.,�. , , Ii...
Facility/Owner Name Fark ID#(if pplic le)
ft.
(451 Bek)I2 4 PLC 44 IA
( �ra4i (�, 1n ft. ' 2023
Ph;;''ysi al Address,City,and Zip ft. ft
County Parcel Identification No.(PIN) '
(if well field,one lat/long is sufficient) 22.Certification:
N W 1( I7113
6.Is(are)the well(s): l Permanent or OTemporary Signa f Certified Well Contractor ' D
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 "No 15A NCAC 02C.0100 or 15A 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same r ou may use me Dacx or tins page to provrae auumunat welt construction iniu
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: { ��ryry 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .D-AJ } (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2(a)100)
i� 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,Raleigh,NC 27699-1617
If water level is above casing,use"++"
(, 24b.For Infection Wells:Cony to DWR.Underground Injection Control(IUC)
'_. ' Program,1636 MSU,Raleigh,NC l/b99-1636
12.Well construction method: aI i r f ola r-7 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
13a.Yield(gpm) 'I Method of test:
b J i�v y • Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: h K Amount: //2- i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018