GW1--01465_Well Construction - GW1_20240301

WELL LL LUIN;,I KU C I1Uly KLt t U1UJ (LT VY-11 : For Internal Use Only: I : .
1.Well Contractor Information: ,
G ,,... tsI ;t; 3f +>ua{ ilsaif .i im, f s 3 k * wSv.s
Well Contractor Name FROM TO DESCRIPTION
D.21 ft. I‘o ft: I /®lJew,
NC Well Contractor Certification Number a1aE}11.R C(po'rmu' caye't1ti$]ls; t I Ij±#ER{ifabpticsble) ,, ;?�
�j)(►I t[1 . Pole,
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FROM I, Ill lVAL1RTF;R i TH7I:KNR.CC MATF.RfAL -
�ALLIJ�{J�ll� �N ' ft1 lilt - ._... puma:
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¢y ft. I 1 n L ft. I Q i in. f S. 5/ 1-,..11, -» -,
,.uWjJ4UJ 1vtiWc % l - ( - 1 4 I I " - V t t P rY� :
D�® :1 ,aii6l ;rol�t" :6111YfY'(geOtLEraii)lxlo§e1ll op r".,>. x'.'i,�Q�s ,t+ .. `'�}:
2.Well Construction Permit#: E,13 ‘ p FROM TO *'� DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft, i In.
3.Well Use(check well use): Q/�yf.••y b. to Y •y
Water Supply Well: RZICREEb,t;Yi k`4a rn>-Y �Fi i S ill t i!i t,{yii iiM;L*6; Y.= l,4V YylS1t.�.'.ii3.J
FROM TO DIAMETER: !SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑yunict aI/Public ft. f
R. T:.
R _._ _ -__ '!i �_....._ .. _`'c i'i o i` ;.I,I AL. J It J ''n,l!
LtinA7- $,4-:tln.._--...._:..T a-,n_�i _...,_. .e, .I ,� , 1 G 9rr s
L$'.:t3<1tUIIT.R{�,;sfi_-,. �>F B r7=c �'�.`,.,.M: t>,'$1a):•,.n_r,.,,,-., 'l`iVUO
' ❑Irrigation ❑Wells>100,000 GPD PROM To MATERIAL.. EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: P ft. 7-0 ft.
J7010111 l L ir4�i,r�p,t❑Monitoring ❑Recovery ft. g.
Injection Well: It., At.
❑Aquifer Recharge ❑Groundwater Remediation '
DAquifer Storage and Recovery. ❑Salinity Barrier FROM TO
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19'SiM D/GRA R ;(lt'appii 1) t., +s? 1'. .:r r �.,- ,ay. F3:
A F M 1 ! MATERIAL EMPLACEMEJ`1T METHOD
D�y:lfzi•Taal rSt�rr :.�. r.:....Ud. ft. i ft. 1 1
�"IT.._..�...T•a-, a.. I
❑Geothermal(Closed Loop) ❑Tracer 40 : t .itt VG.<t 'cha'df tvi iGnecede6 .l ,. '{: . "" : *4.
❑Geothermal FROM �� DESCRIPTION color hardness,solUrock 1, _ n. , etc.
(Heating/Cooling Return ❑Other(explain under#21 Remarks) .
ft,
4.Date Well(s)Completed:f0.) 1 1-3 WellID# /Vt. 5.1 Mill 90 d' ��i too
Sa.Well Loeatia it 'ft:''I , 1
' � LFacilitylOwner.Name Facilitg DEW(if apglicahlel... I„ '� D �.rt. -it y!
clgos k r kvn in., ft. ft
AAocUkX it. f5 t. ; ; MAR 01 7l24
Physical Address,City,and Zip "
k im as ;,n,Imo$ {v a
County Parcel Identification No.(PIN) '
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I. ..
(if well field,one laUlong is sufficient) 22.Certification: 1 JII-
.
� - .0 t 11
6.Is(are)the wells): ( ermanent or ❑Temporary S'v.r of Certified Well Contractor i
f Date
By signing this form,Ihereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Mir;o 1SA NCAC 02C.0100 or 1 SA 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. 1
--<^ 23.Site diagram or additional well details: •
S.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.
"1''d' t �j j 24.SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: I v® (ft.) A
For multiple wells list all depths if different(example-3©200'and 2Q100') Submit this GW-1 within.30 days of well completion per the following:
i
10.Static water level below top of casing: a0 (ft.) 24a. For AB Wells: Original forth to Division of Water Resources (DWR),
IIfwater level is above casing use"+" Information Prc*Sing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
aa � Program,1636 MSC,Raleigh,NC 27699�1636
12.Well ca�n rz ctretinn moth Cu: �}"�_� •
^a.t- a -xx/..a.-e« «,...«a n...I T n....z...._.-z n..s....-iu aT-.i•,...,, t..e. .
(i.e.auger,rotary,caoie,direct push,ere.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: ■� 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /0 Method of test: I I'D,v' Permit Program,1611 MSC,Raleigh NC 27699-1611
•
t 13b.Disinfection type: Mil Amount: _1.1 l,6• 1 ... - j
Form GW,1 North Carolina Department of Environmental Quality-Division of Water Resources I • -Revised 6-6-2018