GW1--01712_Well Construction - GW1_20240315

"` ELL CONSTRUCTION RECORD (GW-1) je/ For Internal Use Only: I
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1.Well cp
ntracior�Information: .
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Well ContractnrNampppe "-FR•
OM TOq/:•. DESCRIPTION �ry
t . 1 ft J 1
NC Well C ntractor Certification Number Yad in Well Company, Inc, ,1a5.r
.O��easnvG�(f�:�;;1�:�e;iae>v4 OR �pf$p ' lise)::,�.:�.<���. t�
FROM TO DIAMETER!! THICKNESS • MATERIAL �S m
ft. ft I 'in.
Company Name . '
P Y :116111!1/M.CASING:ORTUBINlG`(Reatliiiima eldra150' :'11F.y;
e9 ` P)i
2.Well Construction Permit#:OS ii%P`2,32 3 9OO 'O FROM TO DIAMETER• THICKNESS MATERIAL
' List all applicable well construction permits(.e.UIC,Cormty,State,Variance,eta) ft it11111in.
SD i- 0
•. 3.Well Use(check well use): ft ft in
Water Supply Well: F: .7«S.0411. 's a.a'.a",rra.>�...:._.,. -1-- - _ - r R_1
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑,M/unicipal/Public . ' ft, ft. in.' '
OGeothermal(Heating/Cooling Supply) SResidential Water Supply(single) ft ft t in.:
;OIndustrial/Commercial ❑Residential Water Supply(shared) "18:.G103 ; "}� -- —— ---7 -
❑lrigation ❑Wells>100,000 GPD . FROM TO u MATERIAL— EMpIACEMENTMETHOD& M NC
Non-Water Supply Well: 0 ft. 2,.; ft Bt h I?wv i fy xa.i aJ,
❑Monitoring ❑Recovery . ft. ft
Injection Well: • ft ft . -
❑AquiferRecharge ❑GroundwaterRemediation - '
ii19 SAND/GRAVZIIPACK(ifapplicable).�_.__:.�_-___-.._Y = `T:-
oAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD~�' 4-
❑AquiferTest ❑StormwaterDrainage ft ft. I
❑Experimental Technology ❑Subsidence Control ft ft i .
OGeothermal(Closed Loop) OTracer i;2ll:DR.1111/IG'I:OG(iittach additional`stie'etiif.necessary)���_._.____w_=
:ElGeothermal(Heating/cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION(`aloe,hardness,sell/rock type,grain size etc.)
Date-Well Started :13—a-4 AA 0 "• �7-� ft 5 . ,•,' ''
4,Date Wells)Completed: — Wes m#AAP cak X ft (9 7 ft 1Ak ,-.Ocr ,v - F
5a Well Location: J Phone#.70/- 702 yJ71 '( 4 ft. toot ft. �/cr-li. S0Ft Bi cK81,0i^4.11C '
Facility/Owner Name•''�I ' / Facility ID#(if applicable)gg�� • ft. ft I ' i•� '^ -. • - '.' •
ft.
��' • ft.• ft
PhysidalAddress,City andZip ` i. I 'MAR_I l-
County ' ParcelIdentificationNo:(PIN),'
Sb.Latitude and longitude in degrees/minntes/seconds or decimal degrees: 3-'7:_
(rfwell field,one latilong ts''sufficient) 22.Certification: 9 J
. ..,'... .,. .''. 4 ''' 50-.0'‘,,."'..: N `...V6 orleT143?-4 . . 1
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f . : ,,,rr ed Well Contractor ' Date ' . .53
'.,'r 6,Is(are)the well(s)::C ermanent or ❑Temporary
By signing this form,I hereby certrfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or iiIi&fo ISA NCAC 02C.0100 or ISA NCAC 02CI: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. (3
repair'under#121 remarla section or on the back of this form.
23.Site diagram or additional well details: CP .
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(W 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. el)
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (0? (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and z(�100) Submit this GW 1 within 30 days If well completion per the following:
7 24a. For All Wells: Original formto Division of Water Resources (DWR), 71)
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" V)
11.Borehole diameter: (in.)$It Off: °
00 l 24b.For Injection Wells:Copy to IDWR,Underground Injection Control(IUC)
r-� �/' Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: HIS i''��'j/ 24c.For Water Supply and Open-Loop Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,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
{ kir Permit Program,1611 MSC,Ralei0i,NC 27699-1611
13a.Yield(gpm) / Method of test: 1. , peer.....k'
o Date Site Visited: /-
70/o hth OZ Site Visited �® S 4-04'w
13b.Disinfection type: Amount: l By:
Form GW-1 ina North Carol Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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