GW1--01407_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-1) II For Internal Use Only:
1.Weir Contractor lnformal:19: r 1
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Well Contractor NamFROM TO DESCRIPTION
A .
NC Well Contractor Certificatio Number L .5 i4C R �G vi m.r, ft. .57E- ft. ae' ;3,n rr•.r ra.,,an•n<_°_•,r-.•.Y >...:.,::.:
/. `� If .t1 p FROM TO
DIAMETER, THICKNESS MATERIAL,
l 1i-MY r00 1L Ue.ii g1 rio,0 i �' I q Cl n' I f (1 ti 'in.: -11!)r`;
�A' �n� 11q /t «� '3 '?11$ Vitt RQe1STl E51ET.401144. eothecniarigiseH Itiaii ':�<&x `_g4P f' « `a
2.Well Construction Permit#:Li 1 0 ) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.11IC,County,State,Variance,etc.) ft. ft. ! In.
3.Well Use(check well use): ft it in.
Water Supply Well: ,^Ii:`SGzN l j iO a �vq� �'r E. ."s ` J:. Y0 , ti .,s
FROM TO DIAMETER 1 �i I !SLOT SIZE THICKNESS MATERIAL
OAgiicultural unicipal/Public ft. n, 1'1,1
°Geothermal(Heating/tooling Supply) Supply(single)esidential Water Su l .i 1 t i
ft ft In.
['Industrial/Commercial taRPR,,Pfltlat�tarP!C„n..i.,t i.n,e i1
OIILr St10a i .2n.btani1t .W?S5.4 , s».c.:;1::..s, ,,:r. r.': ..CMIPM—,",- r: J, ",,,
v,n
g DWells>100,000 GPD FROM TO MAT y y~ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. D-19 ft l„�e 1-s� I.,u •'.�Y
OMonitoring °Recovery • ft. ft i!i r1
Injection Well: " "(� �� i`��
°Aquifer Recharge °Groundwater Remediation - fr. N>ct 5
°Aquifer Storage and Recovery °Salinity Barrier `-19:SANDI:ORAtlE1v�AGIE(4145lrc of p _ .V3` :<vl . 1 V-tI4 fa>1,.i;
i." FROM I TO 1.MA-TRW Al: r..e ..............::'
OAquifer Test OStormwater Drainage ft. ft.DThcnerimnntalTechnnlnav r•tc,d,.;,tP.....r....+..,r n .,� �yy
. ❑Geothennal.(Closed Loop) • OTracer 2b D 1TI](I+TOT t1 ;Eattaeli'fiddttldti slie te:ftiieeeltisr }z y.. air:;,Q;.r ..W ;; .
°Geothermal(Heating/Cooling eturn ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
(0 ft. 6o rc. G E a ��
4.Date Well(s)Completed: )3 il Well IDp (o n ft Q it �� ire,
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r✓ q 5a.
Well.Location: >t�' ,ft. ,6 1'
Ron
aPkicidi. , ,
Facility/Owner Nlam`e _Facility ID I ft. f. •: . Le L..d 1/ L Li -
%t: � _ ty #(if applicable'
106( )--J��,I tel (;�rior,tJkAklte- It lS' � . ft, 1 MAR v 1 2024
Physical Address,City, d Zip D' IL. 1 •
t n„� 3 a.rn-r Dr. s
Writ k t- krat�ar { Jr`�k<~� ...4, :�;t�`�..vIt:wi�i p. :rr..1 ..?�ri yet v it 9'F T ni.d r
County Parcel Identification No.(PIN) I
•Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I.
_w.._ ___,____o____.___ ., 22.Certificationn j tr
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Iy,,/� fI 9`o " •4 0` ' d-)I 1T d, ', 3
6.Is(are)the well(s): impermanent or OTemporary Signatltre of Certified Well Contractor Date J
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or o 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:
S.For Aennrnhe/nPT nr(Inca,-T r.nn(Snn+h......,..r T17.11_t._-,.....f 'VM,ma,. fl,a t.e:8...Fa1.:-_ __ _i..-:-.7."...
____".. ;.•n • --+.- .
_ o' _...ra.,. - � -��y--.....-...........vu.ic .i,�u wuouuticlUil"i1"d0 -
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yourmay also attach additional pages if necessary.
drilled:, i- _
— rik a+,inlntl'rAL!INSTRUCTIONS'
9.Total well depth below land surface: 00 ft
For multiple wells list all depths if d�erent(example-3 00'and 2®100) ( .) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: g-d ft, 24a. For All Wells: Original form 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: l0 �/tf (in.) 24,,b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC) .
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12.Well construction method: a u r r l • V 1
tie.muter.!Wane.: cti rlirr rr„net urn,_S ✓ 24c.For Water Supply and Open-Looi'Geothermal Return Wens!('any to:th2
county environmental health department ofihe county where installed
FOR WATER SUPPLY WELLS ONLY: 124d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
(gpm) j/ Method of test:
13a.YieldV b J(1)(A) Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: a l Amount: 11 . .1)
tut I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources ` Revised 6-6.2018