GW1--01263_Well Construction - GW1_20240229

•.XV.I.u❑.,%-el."110 ANUUt....IlLAIN ARiCUKU(GW-1)
For Internal Use Only: I
, 3-, 5oh Poort.
I
Well Contractor Name).-11 1 A !1y1'�i E' :SOL�IES,'c�•:''1 ';ES Rx,7 vkw ` ftH' ': �,zo ?,ti.its„4:K' .i f:
FROM TO DESCRIPTION ":fir
ft. 56 ft. n.
NC Well Contractor Certification Number ft. R'
�� �� a YttciVIER C MIN O(f6elt'tlltWalt 11410R2 R. f a t_ .
P.
t, 9 A 9. r,,,kr f FROM ( TO iD1? ) n i liiir, yCa � fL Sft. . I . 6 I A Ir i si�a►n a�_ r
BB I C,1 srto l!!tik K,;t3ASINCsIDI&TFtI IlYf (geoth'erriis�l.eipset:laoji},t.,. ` ;,.kc, o
2.Well Construction Permit#: P 6 FROM TO DIAMETE1 THICKNESS ,MA L List all applicable well construction permits(Le.t1IC,County.State,Variance.etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft i in.
Water Supply Well: .$C fit 'i`e>:.-*ikt: w:.'I �L #: x,1;;fir_, f 0:s : Z ��
FROM TO DIAMETER SLOT SIZE TRICKINESS MATERIAL
❑Agricultural ❑, unicipal/Public
❑Geothermal(Heating/Cooling Supply) i IResidential Water Supply(single) ft. ft i in. J
ft, ] ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) I
Mir'igauun ❑Wells>100,000 GPD FROM -,To: ;".: .TERI�, _, .. LAC '*g tnMET D?F:MO AMOUNT
Non-Water Supply Well: �8M-A-TES y EMPI�+CEMENT METHOD&AMOUNT
❑Monitoring ❑Recovery
® ft. 3-D tt I ricklray�i1"7
Injection Well: ft ft.• -
°Aquifer Recharge ❑Groundwater Remediation ft. ft.
DAquifer Storage and]recovery ❑Salinity Barrier FROM TO A E7iIAblef 4;^" i C'E ,.=EMPLACEMENT
•rl�,�,.,.44 f. .'FROM TO .MATERIAL I,:EMPLACEMENTMETHOD
ii
[lAquifer,Test [1Stormwater Drainage ft it
1
❑Experimental Technologyft._ •� �
❑Subsidence Control
utreofnennai(Closed Loop) • ❑Tracer i
ztfy13R11s•L3NGli Latta+eBadai laftsliiitiVisee"esiariCIM.;°; .,WMry; •
1°Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness,sotVrock type,grain size,ere)
4.Date Well(s)Completed: .) 4 a.LI Well ID# '
35 ft' d'
35 2.`1® '' grourt, 6 4c-K
So.Well Location: ft•
p
ft Facility/Owner Name r- '�' n',.7'"F 1 I CV.
FacilityrD#(if applicable) ft. I f. 1
i %L.� .sll.slVI
135' iki1 i i ice-, —clan In (rt�'Wtoh al p ' FFR 2 0 9f 74
Physical Address,� City,and Zip l tL ft;
J-®" , V •S n Y Y Eira tiillr`.c-t�Cyor.`.rl` `'v .y e,*,... 1 +'t p5, w p��u�.uTn.:?.S�SN��'.iitl..�'L�•*'�f-�.�4t{F f'.�I )-.k�:��t�"��I'%i.,� Udy�;iK....�
County Parcel Identification No.(PIN)
I L oyclt ooii • Y :
5b.-Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelt held,uuo iarilaug,w auuic:ieaii.
ll.Certuicanon: r
N w ' 1Q ) eL.J(i1)-�
V i aL
6.Is(are)the well(s): [Permanent or ❑Temporary Si 6 e bfCertiBed�etl�Coatiactor Date
By signing this form,Thereby cerh,fy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or o ISA NCAC 02C.0100 or ISA NCAC 02C,0200 Well Construction Standards and that a copy
If this is a repair,fill out known we11 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:
R.!.- 77.7.!"1...,n10'r nv r!..^a'rtnr rvnt!u^ ^r U7.u..w-vivr.«Ρh.._mow You may use the back of this pagejto'provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 9
vuanar iHL 1riDllt Ul.11V1VA'
5 v
9.Total well depth below land surface: 540 a)
For mutt ie wails list all depths{l dt$erent(example-3(a)2t)0'and 2®1000 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: a b (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use^+6 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lI-Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
4 ��.y- Program 1636.MSC;Raleigh_NC 27699-1636
12.Well construction method: Of l r rd d f r
(Le.auger,rotary,cable,direct,push,etc,) 24c.For Water Supply and Open-Loop Geothermal Return fells:Copy to the
ovunry environmental nealte department of the county where installed
FOR WATER SUPPLY WELLSWELLS ONLY: 24d.For Water.Wells producing over 100,000 GPD: Copy
13a.Yield(gpm) I Method of test: tow Permit Program,1611 MSC,Raleigh,NC 27699-1611 to DWR,CCPCUA
13b.Disinfection type: )1+k Amount: G L, P 6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018