GW1--01276_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
lI�,- , Lp
4 �a h Poi)1 / eivOUtatzott`s.a4,, 't }. -:..4r`',: t..mp r 3 wz z,..{_.. vimv':,.,:..£3 >e
Well Contractor Name FROM TO DESCRIPTION
ft. ao f° a a 'fur ft. .
NC Well Contractor Certification Number 15,,otralg CAASiNo(Coc inliiivi 5ed mill§yootanitoap"lisat le).' t `
k I e j 4 rot C y FROM I TO y DIAM THICKNESS MATERIALv 4 t:
�� �. Note- � C•t� �`� !•' .tr% ft. F -'P-'d_. ft. I 4 krin:':1 A 4•4.ds"
"LompanyName`'t r p „ 1 i(� I° 1. i ;�
/ rLTG:T KtI Pik.1�at3R•TfI 1N0'r{ieo Nernfa`7'telaili3-frtip . ; rah ."6 I
2.Well Construction Permit#:,c•: O (93 0 " 0 1 0` 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: `r In'S.. 1<l' . ' .2 sn. 4- s fv' x r.i=; r.:_;R::'. R.,;,;M r + w
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ nicipal/Public ft. - . ft.. in
`❑Geothemal (Heating/Cooling Supply) esidential Water Supply(single) g ft. E lq
❑L? - ....—....-.-...1 - . .. . uuYY.J u.uwru.b
,1$4k3i1'I'_ ,fkNRw,. �..arfr..,.''bg.ga..YZ.3...z:} .fix,:.lM.M?e‘74iMa.,i',.1
❑hrigation ❑Wells>100,000 GPD _ FROM TO MATERIAL EMPLACEMENT METHO &AMOUNT
T
Non-Water Supply Well: 0 ft. 7.p it. 1,e ) (1+v fa'I
OMonitoring ❑Recovery ft. ft. .�
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation ,.
19.:SAi`W/GIIA••YFEPAQ (Itiippkcahlej.,, iW s0z;` .-SV),,.; a a a •
❑Aquifer Storage and Recovery ❑Salinity Barrier .FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.A ft.^a
uun!/,..ua.buwa♦„�luaV1VE'j)' 1�u IuUelLLW u.\ l: .imilul 1l. 'I ci. 1 ,
❑Geothermai(ClosedLoop) OTracer ;b.=B IEL N its't7G(s{racriadait7oivatsrleets t`nebe`s`st`tfr Vn , z _L .c,.;
❑Geothermal FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size,etc.)
(Heating/Cooling Return) ❑Other(explain under Remarks) it. '0 ft.
4.Date Wells)Completed/oil 7f 2-3 Well ID# 6° ft. (ei° 8• $!( -t ro cA‹
5a..��Well Lo ation: ;It ' 11. I 1
Del �, r €t ,ft. ter` `i
1 Vi e ` t i"' 'a'''. 0,, A
zI.,
F101ipy/Qamer Mamp t� Fifil T rr i t e.,,,u,..a,i ft ` _ it. 11ama
1SS i ; .t'i At �� ft. ft. `EDG920C4
PhysicalAddres§,Ci ,and Zip H ft Information Prry.lzersirca uhac
1
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . .
(if well field,one lat/long is sufficient), 22:Certification: •
Lr. P
6.Is(are)the well(s): l'fPermanent or OTemporary Sigma erti led ell Contractor Date
By si 'g this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or a 15A 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 thisferrn.
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.
"" " 1 / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! 15 0 -Pf (ft.)
For multiple wells list all depths if different(example-3(200'and 2(a}100� Submit this GW-1 within 30 days of well completion per the following:
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"+" Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC!27699-1636
12.Well construction method: a E t '7dr..Fnr Water,Cnnnlyand tlnun_7.nnn(lentharmal I tarn Wells:Cony to the
(r.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(gpm) 14® ' Method of test: t IU 61
Permit Program,1611 MSC,Raleigh;,NC 27699-1611
13b.Disinfection type: Ic I II Amount: 2 :. ,
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised.6,6=20.11