GW1--04568_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
.111 50 P pbb I e/ , 14,wA•TEItzONJ s- ,..
Well Contractor Name FROM TO DESCRIPTION
re .Zit R. l w n_ �° .
NC Well Contractor Certification Number Pvicetf
AA 15;.OUTER CASING(fors tpulti-cased':wells):OP.LINER':(If applicablt)
(019(1 PQb4£ I I! c G. FROM ft. /O f ft DIAMETER In THICKNESS MATERIAL
`Vp1{y'1II if0 �1I . r Scg a(u(k! 1
Company Name T EA Nr'r
J— 0 0 13aCf .iCONEREASINGOR. : (g ernral'elaaetf-loop); ..
1.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ='17>SCREEN:. ,.:i 5 , i';
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) likesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial 0 Residential Water Supply(shared) 18s;GR.Qti'i . ,> t ..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. 10 ft. by Nib kik a rc u i-k
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation
19.SA ID/GRAYEI PACK:(If applicable)_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft•
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOO(attach additiuual:sheets tftiecessiry)- .. . -
FROM TO DESCRIPTION
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (color,hardness soil/rock type,grain sin,etc.)
l it. 90 ft. GI 0-
4.Date Well(s)Completed: i _ 7-74 Well ID# l Of- 7 0 C 0 ft. /fr® n' rah`k ( Ofi�
5a.Well Location: g{a.r C 64. R. ft. 0
ft. ft. ��' �;--.
(olb!nei So««J f .; :T.. ;. .; .
Facility/tName Facility ID#(if applicable) ft. ft.
9X0S _Raumor 01C.i Al Licht(LSI ft. ft. JUL 3 ' CU/4
Physical Address,City,and Zip R R
144 sk .,.21.12F.MARYLS,:,11 .:Q,..,''''>'=i -::.;:--.'-'..&:.;1 ;.,:-.'7.4?,l7.L7?.-7:?.7tiliU- iil,...tiel;,'...ais-.,:. /!-:Z-;1:,.-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: p v
N a' / ?- '/�
6.Is(are)the well(s): Permanent or ❑Temporary Signa of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o /SA NCAC 02C.0100 or 1SA 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#21 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 info
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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i Z® (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(4)100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
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"++,.
11.Borehole diameter: YD � (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
,/� �/ Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: CV r 6far/ 24c.For Water Supply and Open-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: d 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
10 t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �® Method of test: I ,��
13b.Disinfection type: .- - Amount: I lZ tIr(D
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018