GW1--03206_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD(GW-11 I For Internal Use Only: 0.71
1.Well Centrzpw Info • I .
. c r i re.--C 1 r.S
TO
Well Contractor Name FROM
aVvti ft. 4.• ft. 77) k ce" _ i ?l'Ne-\
'Do 6 — fk n. e.
NC Well Contractor CertificationNumber
y, 0 ,1 tN e t 1 bc11‘,,, i IL t T TD . . . T MATERIAL
Camprny Name S Thai© , • 1G . 4-l` eel, 5 Ne
2.Well Construction Permit#: a d a"f^ - O O ' t a IRON TO DIAmIRI
List all applicable Mill construction permits(i.e.WC,County,state,Variance,etc.) R ft. M.
3.Well Use(check well use): ft' rt. ter.
Water Supply Well: FROM TO DIAMITER SLOT BITE TH[C NNS MATERIAL
Agricultural DMunicipa1/Public ft. ft. la.
Geothermal(Hating/Cooling Supply) °Residential Water Supply(mingle) Il. n. ' to.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATICRIAL Dim ACiaar1T sacrum)&AMOUNT
Nam-water Supply Well: C. ft. � ft. l`-I�U vie 16 e D . .
Monitoring °Recovery ft. ft.
Injection Well: -M' 1
n. ft.
Aquifer Recharge °Groundwater Remediation
Aquifer Storage and Recovery 0Salinity Barrier FROM , TO , MA':TRIAL LACwM'h i MaTRon
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology °Stirs Control ft- ft.
Geothermal(Closed Loop) OTrecer
Geothermal(H g/�l rag> ) OOtber(explain under#21 Remarks) FROM TO u tom,tardiness,saE/roek�py gin raq etc)
4.Date Well(s)Completed: 5(15J 1 014- Well ID# $ , a2 D '"t' f, .^�v._- E
Sa.well Location: 9aD/ft aa..'5�-- , Q 1 c e — 9- s c) rr'�
l 1\ �"s�.11'nQ , • `S t• a ,<s " . c'G-.snit ; 'C e
Facility4no<Name Facility ID#(if applicable) ft ft
Phys' Address,City,road Zip M
L., ., i-,.,.6 0b3 54G 4 a►o,(d .
County Parcel Identification No.(PIN)
Sb.Latitude and longitude is dsgrestdn inutes/aeeonds or dedmal degrees:
(dwell field,me lat/long is sufficient) J ere c-c\.
/ 5O30 ' 4-gitNga,oa,4 45. " w .,
6.1a(are)the wen(s) Permanent or Temporary of well Contractor
� BY ' this form I hereby certify that the sell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or Elfin with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repay,fill out balm well construction twjormation and triplets the nature of the COPY of this record has been provided to the well owner.
repair under al remarks section or an the back of this form.
23.Site diagram or additional well 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (n) 24a. For All Web: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3®200'and 20g100') construction to the following:
10.Static water level below top of casing: L V (ft.) Division of Water Resources,Information Processing Unit,
tf water level is above caring,use"+- 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (In.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,Well construction method: 1`aT C r' OPO�also submit one copy of this form within 30 days of completion of well
(le.auger,rotary,cable,direct push,etc.) construction to the following:
(ic
Division of eInjection Program,
FOR WATER SUPPLY ONLY: f� 1636 Mall Service Center,Raleigh, 27699-1636
13a.Yield(gpm) Method of test: 1`^ ‘ 24c.For Water SUDD1v&Infection Weilm: In addition to sending the form to
` t� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: !A T W Amount ! b 0 i completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016