GW1--01471_Well Construction - GW1_20240301

WELL CONSTRUCTION RECORD (GW-1) . For Internal Use Only: ; ' •
1
1.Well Contractor Information:
JT5®n Pod& ri4;sUYtY Tt;JOroS ,j F i,;ti r ? .;,k a :,moz w c.qia,.,'; .v>,,4
Well Contractor Name FROM TO , DESCRIPTION
gal A. ft. ()Jaeft. g id,‘A r .
ft, - ft.
it
NC Well Contractor Certification Number k Ia;OUTL'RGASIPt6(fo;mulct easet�'wells)OR I,IIILR(ith-Pliceble)
Col(41 P el l ( p 1 et m(� FROM l TO I DIAMETER 1 THICKNESS MATERIAL
0 }I 17 �s/°-�T� ft I ©tC ft. i'514 in- I .u44t ..Ia.11.0d'122-`
company mvame"f
f.. a6.= R.CASl>!TGOR,Tll$1:140(ggotheiriti1feloseii`Jbop). ,- 3,tt.•,::' `.v.
2.Well Construction Permit#: Nam+ td-- e 0 139,1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CountV,State,Variance,etc.) ft. ft. ' I In.
3.Well Use(check well use): ft. ft. ' in.
.;-1:7 RCREE) s E'r .�-'w rT?r. ,f .: `4,t-.1 z?r `.rxR.,04 : s=,.,',a * ,' r:
Water Supply Well: Aa
FROM TO DIAMETER• SLOT SIZE THICKNESS MATERIAL
. ❑Agricultural ❑Municipal/Public ft, it. , • in 1
❑Geothermal(Heating/Cooling Supply) [reStesidential Water Supply le 1
PP Y(single ft. ft. in.'
18 ,zC.;l?,.`GRORT tii:O 45.c.c.. . N ,;1-gr " - l.a..S .? :: a r...y:; _.si�v
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL Ei IPLACEME T METHOD&AMOUNT
Non-Water Supply Well: 0 it a-O ft' W kin i ray'
❑Monitoring ❑Recovery ft ft. —
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
194ANDIGRA EEZPACK(tf iiillefibli eii- K n:..` .:„ i ,,°, , {``r-a
•❑Aquifer Storage and Recovery ❑Sallnity,Barrler FROM. TO . MATERIAL . EMPLACEMENT.METHOD
❑Aquifer Test OStormwater Drainage rt. R•
__ ..
❑Geothermal(Closed Loop) OTracer fr2b4Ttl ILIA PG-tiOCr(atiacliaddst anal shecia0t ecessli ii• s >, ;:N
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) -
U p �2 0 ft. p5® ft. �4
tsri
4.Date Well(s)Completed: 1 "" 1 d 0{ Well ID# 011 51 i SO ft. 9 li®ft. Y. 1-k, rr
Sa.Well Location: aecar Cref4k it: ft..r
..ft. t. ' ,
�CO* � S
EacPy/rlwnnr Nunn r Fari tiny wilt of annlirahtnl .ft.; .iL _ pi 1',.�( -0 ... 1 ..-�
1_'_O OVie eh.1 MitilidiestXft. ft.
-t,_ ...� li
Physical Ad. ,City,and Zip ft.
rtrr ft. I I MAR 11f 3 2UL4
NICK—Ir 3 S*.3 .-. �:,REmmiaa.�:�'t „; -C t r.7 rt b C dt 4 1 •a-"r# h£,_iliv l,>;.
�.. � -'ri t ".-:.Nd 1,, �€' w;•'a &:i�a..wan)x.+ti:'�
..'17RVw�r+w�.. ..
County Parcel Identification No.(PIN) DW G
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one Iat/Iong is sufficient) 22.Certification: i
ii rr`
94 1 CrOIL. i.., r — ?c,i
6.Is(are)the well(s): derma/lent or OTemporary
Signs of Certified Well Contractor Date
By signing this form,I hereby certify that lthe well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 414o 15A 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#2I remarks section or on the back of this form.
23.Site diagram or additional weU details:
8.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.
drh'' a 24:SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: gJi 0 (ft.) Submit this GW-1 within 30 days;of well completion per the following:
For multiple wells list all depths ifdiffrrent(example-3Q200'and 2@100)
10.Static water level below top of casing: )-e2 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ifwater level is above casing,use"+" fps Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1LBorellole diameter 6-I `I (in.) 24b.For Injection Wells: Copylto DWR,Underground Injection Control.(IUC)
Program,1636 MSC,Raleigh;NC 27699-1636-
12..Well construction method: air ro ltl 4 e1 24r..For.Water,.Sunny and Oren-7..00D Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct pushy etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) S Method of test: 'la Itiw Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfectlon_type: A -h Amount:.J.. .2.„L.4_
Form l.GW North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018
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