GW1--01464_Well Construction - GW1_20240301

WELL CONSTRUCTION RECORD (G f) [For Internal Use Only: •
I.Well Contractor Intormatlon: I I
P661€,
y, ,/�a S6.b _ rl•4e :1�•.�l'iR,� 7+.+aw�t�3,.tls.,�yr"{.�:�5 rv 'F,d+..°au i�•.Sisq,r,'tics 5i°2��iry .b'a'�*r,..._f.1'i,;Mt::. ..y.Well Contractor Name FROM TO DESCRIPTION
ft f' I
. NC Well Contractor Certification utnber (_ 1,'()Ei'fit;'R't',A,SI(5,I';.(til-Intuit-Vicecl sfellsl°CR II'qtR`fii"apnlieili e1 ' `
aura oky rat , t, B c PIA N, I rxvar -;v-- iHAri$rax 1711Lr.rvn3y „t.:i�twu'..... y.
_:,t_ F C� ft. �� ft' 6v�� In. i fi Iatr.1tlre'J ..t!
5- <>16 R�'G�ASifid IET-td ll�ataefllermelk:tefi Thin� irkgkig
ff r z(1 ';,i
2.Well Construction Permit#: �� 00(4,✓ FROM :TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc) ft. ' ft. . lo.
3.Well Use(check well use): ft. ft. t fn.
Water Supply Weil: "kf .,SCRE'i T k i e�1'�.�i�3'f.#iW��as r�w1 w'�r+zt4;.rc4'z�vACVi—rsA,izAhW+�ir..f .�t 'S"'F `F.It
FROM Tj TO 1 DIAMETER'1 SLOT SIZE ( THICKNESS 1 MATERIAL
°Agricultural ❑ unicipal/Public ft. ft. in , l
°Geothermal(Heating/Cooling Supply) Oesidential Water Supply'(single) n, ft. !h. 1 1
ClIndustrial/C.nmmerrial ClRneid nti�t LUotoe R„nni,.l�6e.o i1 .� �. .. 1 7 �,
QIrr1 atlon °Well .'._... ..-- s'- -- yaa..tagjus r? ttl:rid? 3 t t°rt, e'Anxx !.$¢tS �T+µ yx x`
2 ttat 1,,.. .:3
g s 100,000 GPD µ FROM TO MATERIAL EMPLACEMENTtiIETIIOD&AMOUNT
Non-Water Supply Well: Q tt. .10 tr. 6eN t (au ,
❑Monitoring °Recovery ft. R
Injection Well:
ft. ft
°Aquifer Recharge °Groundwater Remediation
I9 i3Aa'II)101 1;•'VEL; ..:CY: f-ti pliciible� r '`.•-4. .,3`r 40.itI -"'r x,:-:� 5"+,:❑Aquifer Storage and Recovery °Salinity Barrier FRROMM. i To •
MATERIAL f_EIFLACEMENT lnrnoD
°Aquifer Test OStormwater Drainage tr. Ft.' j
r11:1 »m ri,,,o.,rot.Tonl,n„t.am. nQ„{.�;.ip.,..o r!.,.,w.,l ;
❑Geothermal(Closed Loop) ❑Tracer Za0StiJltl>tr1I+I+G tlI' 3`tsah`attiftloui irsliegws'�frnecl;saaxxv ?:;>t-Ma.M E ,emu
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWrock type,grain size etc.) •
I m ft. so ft. c-i
4.Date Well(s)Completed: a'111111�($J 23 Well ID# 30 ft' 1 0 ft. trek t e. rack,
5a.Well Location: ft ft
P14b1
Facility/Owner.Name Facility IDtt(if applicable): ft.1, ft. F 7-:L L.f t ,
f + it Logic, sect( Crmk, - ft. I. ft. I MAR 1 2024 :.
Physical Address,s,City,and Zip ft. ft. •
Q S tf, 3'4 C a ro L`. 'Rx&1,k*"ra,?Im,a.' gS tdri` if;` srr ," .. •.c as
County Parcel Identification No.(PIN)
aWcb0
513.Latitude and lon£itude in degrees/rinutes/seconds or decimal degrees:
to Wan uelu,one N1Uwng t>suu.uwy AZ.A ertrtrCa(rfrII:
^ cO_ _ , . _ff-,"*. I..r,i -2,
II i VI § tY I / IT J J-
6.Is(are)the well(s): Permanent or °Temporary Signs/of Certified Well Contractor I Date CC
Bysi,; ng this form,I hereby cert/that theweIl(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or o ISANCAC 02C.0100 or ISANCAC 02C 10200 Well Construction Standards and that a copy
If this is a repair,fill out/mown well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthts.form.
23.
^ •_ -�- •.• ..r-_..... ... You may diagr the am haaddiHhnal well details:de additional well eonslrticfionitrfa
Site a
ck of
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See-Over'in Remarks'Box).You Inayalso-attaeh additionafpagesirnecessaty.
1 t 24.SUBMITTAL INSTRUCTIONS
f
9.Total well depth below land surface: A 6® • (ft
For multiple wells list all depths if different(example-3@200'and 2(a)100) ) Submit this GW-1 within 30 dayslof well completion per the following:
10.Static water level below top of casing: �0 (ft.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: P (in.) I 24b.For Injection Wells: Copy to DWR,Underground Injection control(IUC)
Program 1 F76 tli_T$ '.Rgleiah._NC'67699_1 616
IL Well-construction method: clIr ro7Q ry
24c For Water Supply and Open-Loop Geothermal-Return Wells:Copy to the
(i.e.auger,rotary,cabie,direct push,CEO ' county environmental ealth department 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) eDi® Method of test: I 0 Permit Program,1611 MSC,Raleigh;NC 27699-1611
.. 13b.Disinfection type: ;1 Amount: ,9.1Z 1ID
Porm OW-1 -North Carolma'Depariment or-Environmental.Quality-Division ot Waterkesources -iteviseo o-alma