GW1--04535_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 �(�
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FROM TO
Well Contractor Name Iy o it ab 9 P�'
�.�.7 ft. ft.
NC Well Contractor Certification umber Cp.
'`.1 '(St1'flRrA.4IN(:(ftiemuttiasesiwellii:OR'11NER(if`iaDtlicabl- ` ',''`1 �Aroe [AtI ( ? rA,.A 1'HUM I.U. UTA,HY,I CM 1MI-MJVCJJ iMW1NAllAley JPn y^- 1E1113.111111111
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2.0 Well Name a3 V‘ 1 i I.s°'�7. i. �.`.3�. .Ll:'.:.L . .,, .,. ,„. :„to + .r': ?„'
2.Well Construction Permit#: S ........ THICKNESS
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) B. n' In'
ft. ft In
3.Well Use(check well use): _' `F .S` 1? ? 5 13 .t:. u:::{.`?-. yam.
Water Supply Well: � ti. ~E��
❑Agricultural ❑ unicipal/Public it ft in.
❑Geothermal(Heating/Cooling Supply) fi esidcntial Water Supply(single) . fL ft, in.
❑lndustriallCornmercial ❑Residential Water Supply(shared) .51.0.011.00I'A ,t ,.i.:_� , s, :,.. .i; t i.z;: .F.
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL r- EMPLACEMENT ETROD&AMOUNT
Non-Water Supply Well: ° ft'' ZO n' 6elitti-i (QV;
❑Monitoring ❑Recovery ft. ft. v
Injection Well: ft. ' ft.
❑Aquifer Recharge ❑Groundwater Remediation ... ,._ . .....- >;:.=_� a D . ':
19 z4A1 12i S C't(if licabie) .s, r+ 3f::._
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM I To I MATERIAL r EMPLACEME,NT METHOD
❑Aquifer Test ❑Stormwater Drainage it It
❑Experimental Technology °Subsidence Control ft. ft. ��
❑Geothermal(Closed Loop) °Tracer ; .0 iT1a11.1.1NT _attic=+ltididoniil":.:.if' x �' 1 w =
a®'u' +� DFSCRIP soil/rock 1_. etc.
❑Geothermal(Heating/Cooling Return ❑Otherlexplain under#21 Remarks) � 0ft. G(Q 770N color hardn
4.Date Well(s)Completed: al(� 23 Well IN 0 ft.
11131111111713111
ft. tt.
5a.Well Location: .._ .. ,. .
p L� blurs I1 .. .. ....
. , , _ ,
Facility/Owner Name Facility ID#(if applicable) ft. ft.fof tiI LI ft/tw gear Creek ft. It. Y 3 ' s06
Physics ,City,and ZipH' R' 1 - •+F+ iel
ty �},,♦�+-
County N Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
}li DlCII 11C10,ut1C 1'aVlU4g 1b bi+�ill:.iGll:j 61.LernlrCatrUn:
ri
N W ni-v„...
I� I1 .3
6.Is(are)the well(s): Permanent or ❑Temporary
Signa of Certified Well Contractor D�
By s' ng this form,I hereby certifit that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ( No 1 SA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
- - - .- _._ _. •,*• --,-* . You may uce the hock of this page to provide additional well construction info
_ - - -
construction,
only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may aim attach additional pages it necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: D Oft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) n,., .._'... 1 F-i4 hser n<.1,;vl. Nr 1?4o0_1 i;3,
12.Well construction method: Q(r rut q try 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
( I o uj Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �01 Method of test: lz,
13b.Disinfection type: '` -h Amount: 1 II- I la
n:i_, Nortn Larolma Department ot tnvtronmental Quality-Division ot water ttesources Mevitta o-o-lu i a