GW1--04450_Well Construction - GW1_20240730

W.E LL I.:VPIS I K,UI:J.1V1N ltt.A.U.K.0 (&rW-1) For internal Use Uniy:
1.Well Contractor Information:
3'a 50 h fo Olt' 9,_",, -'� 12'. x •s .,
FROM TO DESCRIPTION
Well
^Contractor Name e ft. 440 R 5 9 P111 '...
l'Ict
NC Well Contractor Certification Number �yy�� •
yk ...
�' o3 nt'taela Wi h0.1tIAN a luM"aD tY 1,1h.,: tk
Grad Poo iZ Well S Putroxf A w FR(lvf +Tfl I I]1��7FTRR I THr(KNR_CC M�ATFALIL
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Company Name -:,
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2.Well Construction Permit#: S f l i FROM TO � `� DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. R. In.
3.Well Use(check well use): ft. R. in.
} Water SupplyWell: ;i;FR1OSM REEIT Or. ,,.F r,.. .h4.K;F,}-r.;,,-t..:. y. .i ,>.,a---.7 a. ;.
, DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural icipal/Public In.
R. ft.
Or __. ir'._t:- .7 1 cv. e.. _..'
_ o.. ti.\ a rr.
❑lndustrial/Commercial ❑Residential Water Supply(shared) t GRO![flJ ,', .. .,'0+te a r .. . 'r7 , : ,a,. ":: : '�s.~s`.' 's
❑Irrigation ❑Wells>100,000 GPD Y FROM TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 0R' 6e411-nn t ICJ m(1
❑Monitoring ❑Recovery ft. R. Lf
Injection Well: ft. R.
❑Aquifer Recharge DGroundwater Remediation
h9:S,AND/GRAVEL;1'A_CI('(ifapplicable) _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
. _ _ ft. } R.
❑Experimental Technology ❑Subsidence Control R. 1 R. ,
OGeothermal(Closed Loop) OTracer w31t +1? '-f li+iadttt teietitt=ifzu saki _2" s
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(solar,birdie"soWroek type,grate Axe etc)
0 ft' 30 it GI a
4.Date Well(s)Completed:I 11 1 a`33 Well ID# /'firgei 10 '�0 ft' �,iS0 R' S 11+e, r6 G h
ft:R. �..
ft.
5a.WellLocatlox: j
Nrck,�an F iiif/Kt/kg>n R ;JL 3 9 ��1�
Facility/Owner Name Facility IDb(if applicable)
`b2$ P4hcAla.rFL rathr Fur- uafchd R. kt.:....._._ . .�� ., ';�,
Physical Address,City,and Zip 1., R R DI v
14 ar Nei/ ".79v1a[l .y:`:b ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latfiongis sufficient) 22.Certification:N W I f�o,, w ra J i423
6.Is(are)the well(s): lff'ermanent or ❑Temporary Sigma of Certified Well Contractor Date
By s 'ng this form,I hereby ceri(Jji that the well(s)war(were)constructed hi accordance with
7.Is this a repair to an existing well: ❑Yes or lio iSA NCAC 02C.0100 or ISA 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 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 construction inLb
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.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: OCs (t) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ydifferent(example-3®200'and 1®100')
'1 D (f�) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: O' Information Professing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+„1.
24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
il.Borehole diameter (in) Program, 1636 MSC,Raleigh,NC 27699-1636
19 Well ronetk-nrHnn methnde 1 y
(ie.auger,rotary,cable,direct push,etc.) Ai r 1 0T r/ county environmental Sealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinft over 100,000 GPD: Copy to DWR,CCPCUA
to 'LbW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:13b.Disinfection type: 11 _1 /�Amount:_ 119 y
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018