GW1--00550_Well Construction - GW1_20240125

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'-,eali 03NSE° I 014.61175111€0`-- 11 (61.1K: ) 'For IiitelifillOreVikly-:.'',,,:: , 1 •
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's,;•':t0SS911 Contractor Inforn a u
le ovi CA,c(1,--ht gins .. ., ''', "TROhl•-•- -TOW,--•,- DESCRIPTION
s• Well Conttittor Name • , ,..-1:"."'.1;' .?„F . -;-. '';&,.-.v,:; " .,' , '..:: , rt. -..,,
' POD ' i GP01
Ms.40-4 R. .700 ft 1/2 Crivt
NC WeftContmetprfeIbliehtiat Number 15.OUTER CASING'ffierifilltVedVells)OR LINTERTifiti Iteallrel -
'''Ce;':-;:, V81C.(')/Vell Company ROM TO DIAMETER THICKNESS• MATERIAL '
Itc.• '''''':''ir''.'.1.,q-,- n ' Inc.• ft. ft. in. ` -
Company Name ..161INNER7CASDIG.OR.TDBING:(kelitIfe:rmal-closed:IOlitO= _.. :_....-;7-...
2.Well Construction Permit#: /eirg C 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LOC,Count',State,Variance,etc) 4- i ft IleA=7, ft' la Ve:/, !x!" 6PePt P Lie_
. ft. ft in.
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3.Well Use(check well use): ,
raire-:
Water Supply'Well: ' . i FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural .. OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) X.esidential.Water Supply(single) ft ft. in.
... Olndustrial/Commercial OResidential Water Supply(shared)
DIrrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 5 ft' mole 0.63 goufeci S. -93
OMonitoring DRecovery S ft. 26 ft a`JICht 6rooi pummi 2 -.3 is
Injection Well:
ft. ft.
DAquifer Recharge 1:Groundwater Remediation
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i'19.SA.ID/GRAVRE-PACW(if airpliCable)77,:a.il.'„:.21:_•7:-.:-L-7.2:7:2...-.,--;_-=-_-.1:-. ,
DAquifer Storage and Recovery 1:Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
DAquifer Test OStormwater Drainage ft. ft
:Experimental Technology 1:1Subsidence Control ft. ft p.0 Geothermal(Closed Loop) OTracer c.-20iDItraING:Lbatittieliliciditio-ifilliceitiiflieWilliy-r1==-.77--17.1.. _ii,_ .
FROM TO DESCRIPTION(color,hardness,soli/rack •e,: s etc.
0 Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
Date Well Started "2122 i 23 6 ft 90 fr- . car i
4.Date Well(s)Completed: j (2 gl 23 wellm# AA p- 94/7 9a ". 100.3ft. 6 ,
ft:A.1r
Phone#:[phone] ft. ft. -.,..-......i
5a.Well Location: .
...,-.5.-...+
/•,.. ft. ft.
111rOMA .0 WitH7Pf.. . ,--. nc.,
l'''':c L--la .,t7erf'.7 i'Z'" -,.-... ‘,..,._:,: . , 1....!:.':.
Facility/Owner Name Facility ID#(if applicable) - ft. ft.
S' ,j4- 1 ,lei ,2 g 6Ry ft. ft. C....t S.!: r 1,,,,;• .... : ii :
Physical Address,City,and Zip, ft. ft. jAN 2 5 ?n24 ,
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Jia a, --- r7r..?4t,sn Prr.
County Parcel Identification No.(PIN) C'VCVi'C'5417i&'t9 U .
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
1
(if well field,one lat/long is sufficient) 22.Certification: . , .
3/0 I 35-U 1 N et.60 11 w 12 las31;3 '
6.Is(are)the well(s):„011;f ermanent or OTemporary Signature ftli Well Contractor ' 'Date
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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: OYes or in ISA 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 remark section or on the back of this form. ../..i•
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info. •
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:
i 24.SUBMITTAL INSTRUCTIONS
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9.Total Well depth below land surface: /003 „_„
(It') Submit this GW-1 within 30 days of well completion per the following: • : , ,• .
For multiple wells list all depths if different(example-3@200'and 2@100')
10.Static water level below top of casing: , 24a. For All Wells: Original form to Division of Water Resources-(DWR),
If water level is above casing,use"+"
Y't") Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ..
11.Borehole diameter: (in)Bit Off ale
a" cit3Lit 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: Cu!' I.0-ix,"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
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FOR WATER SUPPLY WELLS ONLY: ; 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) I I/Z Method of test: 4-)i: 41cf• -;f Permit Program,1611 MSC,Raleigh,NC 27699-1611
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70`)/0 hth * Date Site Visited: ' N t, . -
13b.Disinfection type: Amount: 33 OZ Site Visited By: Z.1-7-4-- g..."1,1‘
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gwil,..1, st
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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Price:
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