GW1--03001_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1, ell Contractor Information:
(Vii
2 artriff Paci a FROM TO DESCRIPTION
Well Con:cactor Name ft. rt.
9393A ft.
eWell Contractor Certification Number =,',i'lS4d�jhltiR(v�s) 1(�Y(1�t<``4Jl+tir)E1f�j;0 �)I� (Ij epllc�d
'^/) d FROM TO DIAMETER CTHIC ESS M T'E`RI/AL
i4 s W ii (�✓i �vrnP C�. 1 rt. 7 y re, 115 In. Jr� 2,' ��y 5�
CompenytAame t, ' S ;;1'3,1T012R;. a(Si;N2x(QIt thin tiiiiii)dg111Wi latiiiYz?:., ':,:::,';,:_:.
S W 13//7 —O 24 7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft, It, In.
List all applicable well construction permits(Le,UIC, ounty,State,Variance,etc.)
—
tt. ft, In.
3.Well Use(check well use): : )N 'ky'._.t t.:i d,, b;-p.! i:,%?'1 t�r :y;i
FROM E
Water Supply Well; FROM TO DIAMETER SLOT SIZE ^THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft, In,
Geothermal(Heating/Cooling Supply) mResidentlal Water Supply(single) ft ft In
Industrial/Commercial QResidential Water Supply(shared) o• t. , }; 1 :,.,w, '',c`:< „(�•`,�•�_..sp r?'• !�F
'? , ,f x
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
0 ft' Z,o rt. Dm;;1- _ )a
Monitoring QRecovery ft. 1 rt.
-
Injection Well: ft. ft. ,,
Aquifer Recharge j Groundwater Remediation `i9f•10p/ VDL Pia(*J( y g iil r;..+y! •,;: '`. . y
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
: QStormwaterDrainage ft. IL
, .
Aquifer Test .
—
Experimental Technology ti.\tt' )Subsidence Control ft, ft,
Geothermal(Closed Loop) OTracer };,d;;[1Y 111t511100(p'fapi1`Rti0Tnelielicelia tflIfoi aahV)
FROM TO DESCRIPTION(color,hardness,soft/rock type,grain slue,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. 75 ft. GI o�
4,Date Well(s)Com�tleted;5-1-201. 1 WelllD# '76 ft' 425 ft. Glq K1
rc, rt.
5a,Well Location;
Aaron FoX It, i ft. 0• ft, ft. � � eL ��?4
Facility/Owner Name Faollity IDN(if applicable)
ft. ft,
630 Grave, Rd. fL ft.
Ph deal Address,City,end Zip dX:iFlF71Vft. ':y v.;,.,,.,:.. ,.t'
v1hx- or'd
County Parcel Identification No.(PIN) -; ' —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one fat/long Is sufficient)
35.yN584 N z).g 4,,,m_dt ,..;gixe,
gy0s W , /y--�'`�-
Date
6.ls(are)the weU(s) Permanent ar QTemporary
SiBnature ofCertlBad Well Contract
By signing this form, l hereby cer!(ry hat the we!!(s)was(were)constructed In accordance
7.Is this a repair to an existing well: )Yea or 4No :v/f r 134 NCAC 02C.0100 or 1SA laC.4C 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under k1l re narkrsertlen or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
c.For Geoprobe/DPT o only OW-I is ed I dloa a TOTAL Wells NUMBERng the ellssa construction details. You may also attach additional pages if necessary.
construction, 1 is needed. Ihdloate of walla
drilled: SUBMITTAL INSTRUCTIOa
9.Total well depth below land surface: 1-1Z 5 (It,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ljd(Q•erenr(example.3@200'and 2@100' construction to the following:
10.Static water level below top of casings 60 (ft.) - Division of Water Resources,Information Processing Unit,
((water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�o above, also submit one copy of this form within 30 days of completion of well
12,Well construction method: T y construction to the following:
(i.e,auger,rotary,cable,direct push,eto,) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
;�,6 0 Method of test; 24c.For Water Supply & IngetigI Wells: In addition to sending the form to
13a.Yleld(gpm) 11.. � nn�cr s address(es) above, also
constructi�cnmottho one
county health this
departmenhtn of3tO days of
ha county
13b,Disinfection type:�i/4 t!1 to l�1L Amount: h �e where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2.22.2016