GW1--01404_Well Construction - GW1_20240301

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information: j
`�� 10 h No i s 1 wAmlv>*> a E� J z,0; m, tin
Well Contractor Name FROM TO DESCRIPTION
I43 A ft. 17D it. i pi
ft.- ft I ,
NC Well Contractor Certification _umber r
t 15:053 R CASING(loritntlltt-atEt1we11sj;OR.LINER,"(i lr liable)' {r A � -
Gray
tte it
i Pt...44,3
CbBFROM ITO I DIAMETER I THICKNESS t MATERIAL. +a 4r � a�. 6N ft. A v rl ft f_1 dri in.. lI C.e<1 SI.v Aa_.s_ -�..:-
wu,y,auy ivawc 'I Ii , .,P w� , Qqv/4. g o aa� a v •L jiy
°� u . t i�INNER: •'44sINCr,.oivriFR11A1G(geoth°Qitrisl tlosed'zltio } `>.,A,.iS: _'it ls:
2.Well Construction Permit#: ° -3 — p c FROM TO ,DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) n• ft. I in.
3.Well Use(check well use): ff. ft. ; in.
Water Supply Well: .,k7r:S(312EEN'a > •, is'°;;'':f a '1'..: _• s �s . 1..?s;`.,1�'I.Kas•::,hh"r�-:-yt<:,
FROM TO DIAMETERSLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ nicipal/Public ft. 'ft. : ,ilia
❑Geothermal(Heating/Cooling Supply) lkeidential Water Supply(single) ft ft, in. -
❑W..n47:n11r'+..«....a.::.:1 r1h-_]]_-.:_a a<r-.- n a
------ -_-----rry w...-..,.y 1$.G11.011; i-. . y a ,
a...ev,r,.-..z✓. s?•?....wr" ::,.P;... "*;K.c'r�.'/....,....... f.eg.
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMO T
Non-Water Supply Well: ® ft. ao ft. behlt,ti ire, see rd y dt
❑Monitoring ❑Recovery ft. ft. 9d v6
Injection Well: A _
ft. ft.
°Aquifer Recharge ❑Groundwater Remediation
QAquifer Storage and Recovery ❑Salinity Barrier 1'9S` gGRAVEE' N� it;appucable)�-. ;, r.4. a „d X I V:
• FROM TO MATERIAL .:EMPLACEMENT METHOD
• °Aquifer Test ❑Stormwater Drainage ft. R• ,
❑Geothermal(Closed Loop) °Tracer ;211 DRIt�TiI1VeteiG{atiaiifidditioaai`s7tee#s'lfrieco"ssdr'yy �,r�?�e' -'fi`a.' „..: 'al, r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
I j� A f 6 ff. (50 ft. c 6 t.
4.Date Well(s)Completed: " J�� 0 We11ID# (5'b ft. Igo ft. e �Qf< (o ck
5a.Well Location: , • ft. -ft. ; I y
SC� . -s ft. ' ft 1.�. _.. ,
Facility/Owner Name FacilityTJ lifannih shl-) ''_ ft. ' ' ` "-'L i ii L Lr
%i® 1 Cl'efirtAi(4.4'er ek . ft. i ft. , MAR 0 1 2024
ft.
Physical Redress,City,and Zip ft 1-71%!1,7-5;'''71,27,7
�a t
,`,R ®� ?,21' nit'llICS��t6i,.`M a...h,��?<..`,,.>:h:.i.:'Lc „ ?„�',%1 s.'kh.S�' N,CollOg n .`":;
1 C ,.....4.r.jl7
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field;one lat/long is suffioient)_ 22.Certification: gg��
-)cii
- Ada r l f. ",:.
6.Is(are)the well(s): ermanent or OTemporary r• Signaty of Certified Well Contractor , Date
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: ❑Yes orio 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthts 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#2I 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 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.
drile:
24:SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9 % (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2©100)
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"+" (f t' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11:BorehoIe diameter: �l (fin,), 24b.For Injection Wells:Copy to DWR,Underground Injection Control.(IUC)
1. Program,.1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: cur �F -9 a11 'f! 24e.Fnr Water Snnnly and Onen-Tnon Geothermal Return Wells:Copy to the
i.e.t auger,rotary,cadre,(rrect push,etc.] I county environmental health depalrtthent 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) 10 Method of test: b Q Permit Program,1611 MSC,Raleigh,NC 27699-1611
•
. 13b.Disinfection type: ft f-k Amount; I ' 1 b.
.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6,2018 -
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