GW1--01413_Well Construction - GW1_20240301

rrr,.t.Lu LA:1ay.3_i.recua:-1-10.N-RECORD 1 For internal Use Only: , '
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1.Well Contractor Infrremai�r+- � �
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;ig..v 1'>E2;2,'ZO1<V s N? ; y i ;.ia a w g.mgm. ..:- i . a:: ,4 .....r
Well Contractor Name FROM TO DESCRIPTION
/3-�. 7I A : '" ft. en ft I
NC Well Contractor Certification Number
a15.ATJTETt fri45IlYG([or multf c'sti�ve11"s)O1t L11!iR(ifap"ifda6lel `,.`:.: :.'
g, [: (1t 4 R,_ e ti- c ,,IB a ub - . -FROM TO DLiM R •THICKNESS- -MATERIAL
Company Ntime PP tl/C�-e T� ft' ft.
t 6 in•.
_ :.. .;`;: . .;:',.,c".a, tt.a.v,cea unu:.'v:taeotnermat-ctpset[-1tr�k; a :.+its,,. T x� ;.,2.Well Construction Permit#:C4e ' ,1 `�.11 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits .UIC,County State,Variance,etc.) ft. ft. I hi.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17tsGREEItTa ,.,tit uu ox:w: m:max o , 1
❑A cultural FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑/lytunicipal/Public ft.' •ft. ' ,n. '
❑Geothermal(Heating/Cooling Supply) Residential Water Su 1 s' e `. I '
PPY•O ft.'it ft I ,n
❑Residential Water Supply(shared)
.c 1'k;CR011Th.r. ,,.v.i. -.w-st.b..:>.xi ,,i,,•xw,.c,,,,, .Me,. y..
D1k:4;� �-• Li MIS-'1 UU,UVU Lin) FROM TO I MATERIAL EMPLACEMENT METHOD&At .UNT
Non-Water Supply Well: 0 10 tp6iii o 01! ra til -�'tri,,
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uiferl2echar a ft ft.
4 g ❑Groundwater Remediation
❑Aquifer Storage and Recovery DSalinity Barrier. 1 SAND/GRAVELPAC1G(ifapplteable) ':. r�s�Yt } �,:_ r V,t I3rr,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage. ft. ft. .
❑Experimental Technology ❑Subsidence Control - R. ft. ,
,mar ka.iwcuiuuirl u!racer ,.31i'tiRI13'Y +1GG OG:(atiich�'aciaitio`n illlikBY's:f`neCl'Ss'dty�'"'_rv'.:;,,;,Tt ' .�..4�'A j
FROM TO DESCRIPTION(color,hardness,soil/rock
I❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) type,grain size,etc.)
g� ft. 3® ft. c 1
4.Date Well(s)Completed: [71 Y- la . Well ID# ( ;' 3 CO ft. 1 VO ft P rq7,,irtImift,
r. p QC
5a.We Location:�i kat CQ ft ft. ; J elf -Q:4 8 ft.' ft, •
I -
Facility/Owner Name Facility ID#(if applicable) ft. ft. • " .• t�
4cli
u1 °n 2 trent06 ) )V 4- g, S
Physical Address,City,and Zp V
t it•�I�, �• ft•
ki out. ,;.21',REMAR1$.?%! .. .,_r-. -.-s,'.;a rr..vlttl9 ''6 ett,.a'lrn'3t •
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field;one lit/long.is sufficient) 22.Certification:
j N 1 � } ,
-r� 4
, - o - ire v •r•a . ti
6.Is(are)the well(s): ®Permanent or ❑Temporary Signae of Certified Well Contractor Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A 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
construe:on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'inRemarks Box).You may also attach additional pages if necessary.
drilled: V •
24.SUBMITTAL INSTRUCT-0N
9.Total well depth below land surface: • I g ti (ft.)
For multiple wells list all depths ifdWerent(example-3Q200'and 2©100� Submit this GW-1 within 30 days of well completion per the following:
a-® 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fti) (D )
If water level is above casing,use"+R Information Processing Unit,1617j MSC,Raleigh,NC 27699-1617
11-Borehole diameter: 6 Y (in;) 24b.For Infection Wells: Copy Ito DWR,Underground Injection Control(I1JC)
Program,.1636 MSC,Raleigh,NC�27699-I636
12.Well construction method: air fo � y 24c.For Water Supply and Open-L'oo Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) P
coubty envimnmentarhealth rienartrnpnt of thn rnv„ty There•^,stort
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gp m) Method of test:L 1 toW Pennit Program,1611 MSC,Raleigh;NC 27699-1611
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13b.Disinfection type: hTg, Amount:J°(v II,(J
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7"FornfOW-1 North Carolina Department of Environmental Quality-Division of Water Resource) Revised 6-6-2018