GW1--01414_Well Construction - GW1_20240301

WELL CONSTRUCTION RFIcO11.1D{GW-11• 'I For Internal Use Only: •
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Well Contractor Name
FROM TO DESCRIPTIONr�
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NC Well Contractor Certifica'on Number FROM TO DIAMETER.©, /q�� � gyo SgOUT ate,1SING(fot'mulik:*a t 6110:I L•BIER(tf ap licabte}1 , r: _
,'ili(6.41tY ?0S �✓ }(/� � F.rnJ' 17ETER THICKNESS- MATERIAL
Company Name ���JJJ
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2.Well Construction Permit#: Cdt r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ix.UIC,County,State,Variance,etc.) ft. ft. I in. •
3.Well Use(check well use): 1t. ft. in,
Water Supply Well: .1:h SCRF.UiVWASF Afga. w taa t, :61?-aW- I M:i.W' x s .r i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL�•
DAgricultural ❑Municipal/Public ft.` ,ft. tn.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water S 1
uPPY(single) it it. Irn
❑lndusttialCotnmercial ❑Residential Water Supply(shared) sI8 ROtIT =i ` r v: h gin :..,, , rt t
❑1ri'iguuuu Ci W ells>1 UU,000 UPD FROM TO MATEFIAL 1 EMPLACEME T ME7OD&AMOUNT
Non-Water Supply Well: 0 ft. 3,0 ft it lit, jrcv, d14
❑Monitoring . ❑Recovery ft, ft. T
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ft.
19 5'4r D/GRA"t T.IRACIf(1t: p1ilchbk . f. `'i ?w.i`r 'C an wE >.;:, +i,'
❑Aquifer Storage and Recovery ❑Salinity Barrier. • FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage ft. , ft: . i. . . t;
111 I D❑Experimental Technology ❑Subsidence Control ft. , ft. _ I ,
r.
Iuueocnermai(iiosea Loop) U Iracer iTil ilLLI1+1GLt (atraeh-additional_sheetsafnece"s'siiiy. :.._,")Z -iiM a.s s;
OGeothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCAIP7TON(color,hardness,solUrack type,grain size,etc.)9� 0 ft. ° ft. da
4.Date Well(s)Completed: 1 s �@-5 4 Well ID# ibT -' 3.0ft. '3®0 ft. rtai v r ra 1
oaWit•1 A €tc ft. ft. Vf5a.Well Location:Pfir.6.- ft.. ft
Facility/Owner Name ft. ft. t'� N } ;-++
Facility ID{i(if applicable) 1 ,�, •. A,�,,,F
11 1 eItt rABl q note er,o En �- 9.S L --
Physical Address,City,and Zip p ft. ft MAN 2024.'lYa ag. Cja ' v.k^1tf, j 4 L{-t.-XKF�`�i' S'1f,�,:�CM.,1 a
County Parcel Identification No.(PIN) tniOtet+�t.,i r'i ,sw.wc.4 ..r..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I t
. -(if well field,one lat/longis sufficient) 22:Certification:
.:/ N W nA # lli•!A. :e "lc"'-I.4
6.Is(are)the well(s): 1iPermanent or OTemporary Si natiof Certified WSll Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or iisio ISA 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 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 GeoprobefDPT or Closed-Loop Geothermal Wells having the same
construction,only-l-GW Fisneeded. 'Indicate-TOTALNUMBEROf wells '(add'See Over',i .Remarks'Box).'You'mayalso attach-additional pages ifinecessary.
drilled: d 24._SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: 3 o (ft.)
For multiple wells list all depths"different ant(example-3Q200'and 2Qa l00� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 5-0 (ft- 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing us��e°--"l" ) Information Processing Unit, MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 9�`� (in. 24b.For Injection Wells: Copyito.DWR,Underground Injection Control WC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: arr Q( 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable„direct push,etc.) county environmental health denaitment of the.ncnsnty where inetallell
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
Method of test: 6)a%A) Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: k,+bd Amount: 1)7. IT-
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Form'i',W-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018