GW1--01138_Well Construction - GW1_20240216

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well C ntractor Information: 1 `
�k Ore-- PAG e-tf aa`r'WA'ticzQNES-' ;:i.,.':.:i ' `>':;.. c;F:: .
FROM TO DESCRIPTION
Well Contractor Name
ft. ft,
451,c4 ft. ft..
NC 11 Contractor Certification Number
I e—
.np //A, f �� Oi)
LY4 G' e'15 OUTRGA$ING'(fo`mu�plt+cesedivelis)`ORIIN R(Ifap'Ilcabte)r:'•,
FROM TO DIAMETER THICKNESS MATERIAL
' ft. Z ft i r6'n' ✓10 ;._) yR
Company Na a
i..,.74:.,.
/// / /�� /� : .1'BIIVNERty(YASWG::QR`PUHINC(�edtlicrmel>rlo3e8?lorlp)
2.Well Construction Permit#: 6Itr ke.-—1 t& /'e ypii7 ICI�' FROM TO DIAMETER THICKNESS *MATERIAL
List all applicable well construction permits(i.e.UiC,County,St le,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. In.
17SSCREEN _, :,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft, in•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Irrigation ft. II• In.
Residential Water Supply(shared) h1ttT.GROGT; ' .:,. , ,.k - . ''
FROM TO MATERIAL;-- , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1) ft. )st, ft. be12(intte_ ill, e v_13 p-Lt-Yed
MonitoringRecovery fL ft.
Injection Weil: 0 ft. 1----ft.a
Aquifer Recharge 0 Groundwater Remediation ',19}:SANO/GRAVEL:1*A0k4ifsatinileaUle) r: , * - - .
Aquifer Storage and Recovery = OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer *:20i11RILIiING%I O:Cyr(utteohisdditlotlallilieete ff iiiiel eiy)i.:,.,.'•.'...-:,;': , .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,solFroek type,(rein size,etc.)
ft. & , ft. J y.; (-1 k y
4.Date Well(s)Completed: 1•'.:2314 Well ID# 3 ft'
,22-/5ft. j.l'A-ht te, /
ft. ft.
5a.Well LLocation:. /
s L
) d46 .Y V l LAY °U ft. It. ,:: —,7.--!1 1, {..,:
Facility/O r Name q • Facility!Di/(if applicable) ft. ft. " �' ?.r
. • 3 g 7 3 kVi n K-nr. ft, ft. f t6 I ( 7n74
Physical Address,City,and Zip
ft. ft
,S Y 1/6 ;,21t RE141AgNs _.�_ •. i, its r5:!!"4.71?I£,' ;(;'y";UM .. •
�( j` IAt iOUG
County Parcel identification No.(PIN) -
-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; •
(if well field,one� 1at/long is sufficient) ( / / 22.Certification: '
_ `!D/�, � Cj1 N U LO /�I iP CS w Signature of Certified Well Contractor v Mi(/� Date 4,..:_2 t"
6.Is(are)the well(s)0Permanent k or Temporary
By signing this form,I hereby cerlt&that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or qt..; No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the ' copy of this record has been provided to the well owner.
repair under till rem arks section or on the back of thls 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 site details or well
construction,only 1 GW-1 is needed. Ihdicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: , 4)' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdIferent(example-3@200'and 2@l00') construction to the following:1
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter: % (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rf 1
above,also submit one copy,of this form within 30 days of completion of well
I t -r� construction to the following:;
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: a_i r 24c.For Water Sunnis,&I
/ Injection Wells: In addition to sending the form to
i \ the address(es) above, also!submit one copy of this form within 30 days of
13b.Disinfection type: el 1/2 r i Y('e_ Amount: L completion of well construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Re'ources Revised 2-22.2016