GW1--00957_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD(GW-4) For Internal Use Only: • '
1.Well ContractorIInformation: •
•
12.e,v ‘ `lc.- eaNi E r \\GG 1 V 14:WATER ZONES 'ti-'. '..:-.
Well Contractor Name r FROM TO DESCRIPTION
d � yet` q�o ft.
ft. ft.
NC Well.Contractor� Certification Number
'l ( ( % 15..OUTER CASING'(foi-Multi-cased wells)OR LINER'(if applllcablle)'1.;. .-:.-
ATERIAL
!- Mom`\ �� •\M'e` \. t--.‘ 1 k `�C '�\I ft. �y ft. l I /'TO DIAM TER in. ' TH�K.Y `p Vc
Company Name J b @3 l 2
r7 16.INNER.CASING:ORTUBING(getither"mal-closed=loop)3' - .=
2.Well Construction Permit#: : 2 r G- 'J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17:SCREEN a. .•:.:.' ::i_'
-FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• ❑Agricultural OMunicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. ft, in. •
• ❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL \ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: .% 0 ft. (1.0 ft. Bcnw t4 (mm
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge - ❑Groundwater Remediation
19.SAND/GRAVEL"PACK(ifapplicable) ..,
❑Aquifer Storage and Recovery . ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ;. . ❑Stormwater Drainage ft. ft.
DExperimental Technology • OSubsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer .20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,1 soWtrock type grain size etc.)
g ft. /O ft. �e'"G iJ c1 GIG'.
4.Date Well(s)Completed: 0~��t 1�-�1 Well ID# /U ft. 2C)ft. ra,,„NJ 5 y. ,
5a.Well Location: , '-2.C> ft. , 00' b -. \q
ft. t3.
Facility/Owner Name FacilityID# i Y ft. ft
Y ( 1' y PPlicable) l'"-; r `--,r^_-,I pa rrfi•••.....
q v 3 Gil ei r1 lQ i1V‘\�` eti/Y1 S Rg ft ft. •• w`a L Le�{ 11' t L
Physical Address,City,and Zip ft. ft.
•
�/ ,y i FF R 9 8 7Q2A
V n k on - 11``1-1-O1 o PA
County Parcel Identification No.(PIN) ln1ka:Artie:i PfDCast3IP•-%.l)r:+1
DWQ/to .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatllong is sufficient) 22.Certification:
34 .g l'3 t 1 N 8 6,5%S-5-4 W � _ t i
it
124
6.Is(are)the well(s): ClSSPermanent or ❑Temporary
Signature of Certified Well oC ntract�orr Date
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 Oslo 15A NCAC 02C.0100 or 15A NC/IC 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.
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S1)C) (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
-3 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: f (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"• �_
11.Borehole diameter: 6! (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ah Sr 1l[7m f'y 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 T Method of test: Pt
(gpm) 0 v \ t- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: \ c