GW1--01274_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 '
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Well Contractor Name FROM TO DESCRIPTION
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2.Well Construction Permit#:.1-o� 4✓ 306— 0113 1 3 FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(1,e.UIC,CountyV,State,Variance,etc) ft. ft. 1 ' in.
3.Well Use(check well use): ft, ft, t in.
1;;,"SC 1p lc"s aai.N.�a C.Sir ;Ytki.�. xr., 'M,TH.�. :;a,#YdY ?v4.;�, n {M S
Water Supply Well: w I .a >,
7,A,"_s,.:.?:::,_! n7+4;,-,t,r.,,.Iin.t,t. FROM TO DIAMETERSLOT SIZE. i THICIGVESS MATERIAL
❑Geothermal(Heating/Cooling Supply) CidentialWater Supply(single) ft. ft. I is
Dlndustrial/Commercial ❑Residential Water Supply(shared) I
I
l'Y 19.S,ifLYa. me''a=:sa�i�s,:.t .:Y. .':5 ti �` n._._
❑Irrigation ❑Wells>100,000 GPD FROM ' TO MATERIAL EMKPLACEMEN METHOD&AMODNr
Non-Water Supply Well: b it ft.
❑Monitoring ❑Recovery ft. ft. tom/ � �f
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation
2rosA1VbI ff_rks'P'`CLCti g te') 'r, .� ... � iy
❑Aquifer Test ❑StotmwaterDrainage ft. ft. —._........_ _.__...,_.. .
❑Expetimental Technology °Subsidence,Control ;. Y'y ft. � fa.i
-]❑Geothermal(Closed Loop)
❑Tracer
IP) O:DR76f1N1GTstIEMilttach addittliasheaisit neccs3at'y; x w r ..t
❑Geothermal(Heating/CoolingRetum) DOther(explain under#21 Remarks) FROM To® ft. ft DES(CRIPIION(color,hardness,sonirock type,grain size,etc.)
pow
4.Date Well(s)Completed: r��c 11) Well ID# q,1 ft. .DO ft. 31,°'�t_}. 1--0C .
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Sa,Welt]Loea n:.. it. it.
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Facility/Owner Name Facility ID#(if applicable) ft. ft.. r...i V L.(,,,J
I .5 rkei4, f . 1•
f ft. : FEB 2 9 2024
Phy'cal Address,City and Zip ft. ..
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�l�"'� l�li�y � `vh hi•a.r.x Y! F A, s+s K r r .sir}. y r- ... +`y"+'s+Yt.�cs Y � `fi t L
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Co ty Parcel Identification No.(PIN)
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(if well field,one lat/long is sufficient) 22.Cer i ation:
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CAP v ry 1u `� �I
6.Is(are)the well(s): ermanent or °Temporary Signatui f Certified Well Contra ror Date
By signingthis form,I hereby cent that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or DC 1SA 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 k uu luny.uai, A.u4wa va I. Ya6Y,:wpivv:ui,auuxa.vnai VT'via.,�:Wu,.,;;;a.,,:;,;;1
constructiqn,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 ,,;gym, .
9.Total well depth below land surface: ' " (ft,) Submit this GW 1 within 30 dais of well completionper the following:
For multiple wells list all depths if different(example-3Q200'and 2(411001 y p
10.Static water level below top of casing: 7-0 (f,) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
„ v,.,--.+-.:1.,;I:l.r„c•ten. .. ,S9, rob.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
ts-ugram lino!VIOL,s.aieiga,iv�!4rovv-ioio
12.Well construction method: ( ' �� 7 24c.For Water Supply and Open-L'oop Geothermal Return Wells:Copy to the
fi a an"ar_Mary r,hta-dirart r.i,c5.et&) -_ .. _. _....... .f . ,-., ....,,
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FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over lOD,000 GPD:Copy to DWR,CCPCUA
• 13a.Yield(gpm) .. Method of test,
tii&W Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: / i,+//1 Amount: 1 h
Revised 6-6-2016
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