GW1--01466_Well Construction - GW1_20240301

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I ! • _
1.Well Contractor Informs 11
on:
I4 �•' �y� qS,�q �j � Syr n ,
.J 0 ' 6 f 661/ �L/ .:, a'sT* 'T15, h`+ (].l\1' 1�31�,a.#-•*Iw`�ta.�a'i '�,t:w....., *.,.tT..1.:. e`'4.,. ..x'�T.M 3.r x+4 r.,. T
Well Contractor Name A
�lFROM TOy DESCRIPTION
fl19 , ft. I/ 4t9a f G ��I ft ft.
NG Well Contrfiraactor Certification Number y 1'S.;OtJT#R:C SING(fo"r"much xased sfetisyiblt,Lll� i (tf:ap ic361e) >;,:.:,,-', ., ,
�j� yr, p` FROM ' 1 TO I DIAMETER THICKNESS 4{ MATERIAL
66�6WeU N l , ft. I /ell C ft. l I �Il,il in. I 0 G'or A J
company mime 'P , �� �ii 1 A 7, I t I e I.!. 1 �I ti u u I� /K
3 .reatINE1 castle ,t1":T-lati ti a atberm elaseoa °� #{f � :,;,..
2.Well Construction Permit#: 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): ft. ft. in.
Water Supply Well: i19':4.5CRE)rN.:-r. X 2.?,;*m: .� komza.'aoom ,..-„Fr".?;W iiizi emmy:.
FROM TO DIAMETER i SLOT SIZE THICKNESS -MATERIAL
❑Agricultural • ❑I Iunicipal/Public ft.. ft::
l i.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. 9n:
r-,.. •. .... ::''YY'i uu w; 148:.trRt)IITA^`�_..t'.:.Kr,aF -0P,..:£r'Y la:_WMOIVt,fO,_..._ _ ,5, .'\ r'h...RI;.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMEi METHOD&AMOUNT
Non-Water Supply Well: ID ft. ft• rd lit i e i raqi
❑Monitoring ❑Recovery ft. ft. `
Infection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
OA fifer Storage and Recovery ❑Salim Barrier 2' .SAND/GRAIrE;,l'il;CI((if appileabie), .t,s- ,.,, ;.yxr'-,_:�,;r5
g _ ty .. FROM TQ .MATERIAL _EMPLACEMENT-METHOD
It. ft.
❑Aquifer Test ❑Stormwater Drainage ryry
ur...2......uvu,-"• awuuvaVrj) LIUVVJ1LLW11.:1:WA:1 i ,'. I ]la i� v
❑Geothermal(Closed Loop) OTracer .2i`I1lf(]LTiINDIOLOTattatlil dilitroudl sheds ff'lteetiliiiiaylw ...) n ca" ;.'r„
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,solVroek type,grain stze,etc.)
•
pp 0 ft. it 3O ft. c.L&��
4.Date Well(s)Completed: Imo' ®6,4 Well ID# It+ 111 3 130 ft. I go ft. ' rth t4€A ro&K
5a.Well Location::Biii,5 .r (-rut
' .ft.
;fr -it.
•
Facility(OwnerName. Fagili;MA rfaa,rio\rat, . . 'ft. ,• -ft. Is r... 1 v t
1 AI' ft.
' % air ( [A vi Ih.� /�'� i� 1�5� ft. MAN 0 1 2021
Physical Address,City,and Zip
NIr S y�3G# S. i ,:.2tr; R10r'` 't...;'Ya',�13.c' ...IM4 }4f $ i r * 'l' .>. ..:t•.r-
County Parcel Identification No.(PIN)
Sit-Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field;one let/long is sufficient) . 22.Certification: 1 -
I. A- lip ..,_: .e
( fin ia1 4e
6.Is(are)the well(s): ll ermanent or ❑Temporary Siagna,,ewf C�iatl Well Contractor Date
/1 By s g ing this form,Thereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or l:No ISA 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:•
8.For`Geoprabe/DPT or Closed-Loop Geothernial'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.
dzif1 'r �[{� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lJ&a (ft) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3®200'and 2®100) p g
10.Static water level below top of casing: .;-,® (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: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
• `� lrrogram,-1-636-MSC,Raleigh;NC 27699-1636--
12..Well construction method: (C �� 2dr Far Water Sunniv and f)pen-T.nen(:enthermal Return Wells:Copy to:the
(i.e.auger,rotary,cable,affect pusn,-etc.) / county environmental health 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) /0 Method of test: I IOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: h:'111 Amount:.Al.. 16
I
Form:GW4 North Carolina Department of Environmental Quality-Division of Water Resou I es1 Revised 6,6.2012