GW1--01285_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -
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Well Contractor Na amme FROM TO DESCRIPTION
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NC Well Contractor Certific on Number.
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1' ; ®3 p(� UR--P,_ Aen140" FROM TO DIAMETER _THICKNESS :MATERIALCompanyName Aq 1 YYY0 t ft n �' 1ti p In.
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2.Well Construction Permit#:t 1 1 f- . U C t�1 6 FROM TO•w v-- DIAMETER THICKNESS MATERIAL
• List all applicable well construction permits(i.e.UIC.Count,State,Variance„etc.) ft. ft. in.
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3.Well Use(check well use): ft. ft. in.
Water Supply Well: •',41:SCREE;rat ,.:..',;, t'.§ tl.-.:.tit' '•':.;t`'' yjt'4;`c :V:y .:;:g0; .::4;.
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
. ❑Agricultural ❑ unicipal/Public -ft. in.
❑Geothermal(Heating/Cooling Supply) EIResiciential Water Supply(single) ft. • - ft, i in. -
❑Industrial/Commercial ❑Residential Water Supply(shared) x fir.
Dlfi 6auun Li Wens>1 UU,000(it'll FROM TO A EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: ii ft. 10 ft. beh i to r Q f
°Monitoring DRecovery ft. ft. RI 141
Injection Well:
ft. ft.
DAquifer Recharge DGroundwater Remediation
DAquifer Storage and Recovery °Salinity Barrier 19...SAND/GR,&1 ELPAt f(tt;.applicab1er i s'r ! • .,s„ , ...4 .7,`,,, x
= r..
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test °Stonnwater Drainage ft: .. • ft.. . '
❑Experimental Technology ❑Subsidence Control ft. ft. . i
uueocnermai t.Ctosea Loop) Ll tracer Utinifd✓7,T1+ftrt G:(altackaddiilanal sheefs:tf'rtecesset l;Wt`l& Y „V4
❑Geothermal(Heating/Cooling Return) ❑Other•(explain under#21 Remarks) I FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
:I_�� 0ft. �® ft. a�'Ace
4.Date Well(s)Completed: Well ID# ao ft. 3 .o ft. q rgmilG to a J(
5a.Well Location: . ft. ft. LI
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Facility/Owner Name Facility ID#(if applicable) ft, ft. ; L,-.a r L.L.t V L
/ tt ro-e.� / illy-- rq Ln�a3NI,rr a 11>i 1 :.. ft. FEB 2 0 2074 ,
Physical Address,City,and Zip
T1 12EMAI2IC$ri„. x;�{;�.o s:e f_.r, • ! r r'�,e,.t'iT„'::, �..C i:.-r7.Art,i x'?-
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/longis sufficient] 229 Certification:
:„
N . W il,,A P._-J9 1i ' 21511% 1114
6.Is(are)the well(s): (IPermanent or OTemporary Signiue of Certified Well Contractor Da
By signing this form,I hereby certj that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or 64 1SA NCAC 02C.0100 or 1SA 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:
You may use the back of this page to.provide additional well construction info 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
-construction,only-1-GW-1-is-needed.-Indicate TOTAL NUMBER-ofwells ,(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: ..dO (ft.)
For multiple wells list all depths If different(example-3Qa 200'and 1©100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (fti) 24a. For All Wells: Original farm to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11,Borehole diameter 4��yt (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,..1636 MSC,Raleigh,NC;27699-1636
12.Well construction method: (c �'® `' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,,cable,,direct push,etc.) eouiity environmental health denarttnent of the ccutnty where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: blew Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: iltk Amount:.a''
Form GW 7 North Carolina-Departtnent of Environmental Quality-Division of Water Resources . Revised 6-6-2018
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