GW1--01468_Well Construction - GW1_20240301

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I '
1.Well Contractor Information:
ation: y r �Yr r�nw�z�
CI • K.� f' L. �LI i i P�VC.Well Contractorllaama VV�� FROM TO DESCRIPTION
e -/-I1 A ft: /8b 1e` pm
i
NC Welt Contractor Certification Number Y5 OTIVA(+ w,IND ff„F ililItritg r, )aR :tiCarup;icalife) `'°;`;
_ :74;5 O h ®o i.e/ rttum it) •u1,iiYrl•:rhii •ItiltliiNL liieil L'KLii.
(/ 1 0, it. L 1':99.; ft. I i. in. I a .ci I I el isl_sr a 6141.e;:4,
L^,!3 b b 0 foG 3 :xttII R rr r s ektr tberin tgaii;ft of .MVi i. .:� }
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft. In.
3.Well Use(check well use): it. it. , , in. •
Water Supply Well: 141TsSCItBB1Vi PM:4Y..,-t.7ati.+: KS� ,W: n-;.,3 a s nz 4s.,, 2E1 z;.' Wft';.,
p FROM I TO DIAMETER!'1 SLOT SIZE i THICKNESS I MATERIAL
°A cultural ° ci al/Public
°Geothermal(Heating/CoolingSimply) esidential Water Supply(single)
ft. I ft. In.
QirrinatAell('n,rmnrniol nR xidank:nl\11. ..C..n..l.•l.:1.n b.rl '' d i� .. I__.—._.___.... ' I.
'�. r. '1W.:i'xJCUtl�l,�r eP `7�`3-v�!.:!1Yi " .S. n�`.,C M,_.r,?X�.`F,:•rI - `'" �..�: .h�h ?'.;�+N xi4i
°Irrigation °Wells>100,000 GPD FROM TO MA EMPLACEMENTMETHOD&AMO[tNT
Non-Water Supply Well: D it. �® n. 6eh l�� r-Q V i17
[Monitoring °Recovery ft. ft.
Injection Well: it.
❑Aquifer Recharge °Groundwater Remediation
*xJ.5' 1GRAVBC.V iCIC:U" $pi iclihiel .ia:r i- *:,i i s, t14,.,0�7 ;4 fi:si
°Aquifer Storage and Recovery Salinity Barrier E-FROM I TO C:MATERIAL_ }EMPLACEMLNT METHOD.
I°Aquifer Test ❑Stormwater Drainage It ft. ft.
1'7II..�..��-..�..1-(T.....L....i...... n „Ln:.i-...2 f+..,r0,-.i �7:, :�+ '-ft. 1 1'
❑Geothermal(Closed Loop) OTracer1)Yilsllidisii�atitkautegfsit nece3da'c"9 ?r�x �u ..:� a
OGeothermal(Heating/CoolingReiurn) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,eta)
ft. To ft. GBa
4.Date Well(s)Completed:11-(1°1,3 Well ID# t6 ft' �.DO q rgy1 nft (oc,k
5a.Well Location: _ ft. -ft. , .d 1
pL' b"a4(5 L. : t. . p. .=_.0L �vt
Facility/Owner Name Facility ID#(if applicable),- 1.. ft. I. tr. I- I; •
.? o AI Beau er C re1� �7 ft. ft.
MAR12021
Physical Address,City,and Zip ft. ft. lI1@iji F.; lS+tii•
T1n
Afa 6 h 3'1 13 c 3 rtittw �r,:� �,,,r1:N,,4 ��r > 5 l�: i_4,
:.v��+wt'���a:J x�i�i. .K.-�R- �.isx'!i-._.uA�2 ..tC' .;.94i .�.) > c�7S5'y'P.:,.
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ii Well Geld,line Laulung is WILLIWCW.)
zz.uerturcauou:
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7.' �. off.; t-S' °�"-N ,7a-:S
6.Is(are)the well(s): dPermanent or °Temporary Signs 'e of Certified Well Contractor 1 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 to ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. ! 1
23.Site diagram or additional well'details: .
: :,._. ... : _ -a - r R.--. You may use the hack of this nag ton vide additional well construction info
•
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells
(add'See Over'in Remarks-Box).You may also attach•additional pages it-necessary.
drill . B 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) I.
For multiple wells list all depths if different(example-3©200'and 2(4100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: a 0 (ft) 24a. For All Wells: Original forti to Division of Water Resources (DWR),
Ifwater level Is above casing use '+ Information Processing Unit,16I7 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: On-) 24.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
roartIm 1636.MPC.Roleioh_Nr'11699-1 n?Fi
-12."Well construction method: a l r rel T r'J 24c.For Water Supply and Open-L'oon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,came,curer:pusn,etc.) % county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 1 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: b lb J� Permit Program,1611 MSC,Raieigh,INC 27699-1611
13b.Disinfection type:. �t� Amount: :<t-•
Form'GW-1 itorth Carolina Department of t nvlroumental Quality-Division or'Warer Resources Keviseao-U tubs