GW1--04569_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
fao� PcL (04Ii 4 ettvv‘cco. :r� , 4.,. LF ir =L� a WO.':Well ContractorFROM TO DESCRIPTIONr -�.719An, /8b ft. le3Pm
ft. ft
NC Well Contractor Certification Number r.t
f;;(TLi'f`F.R C`:451Nf`f�`w�:iiu'ttf.�cdteb'�vellsl:t)R;t11VER`(f£sodlicgbl'el' '
Tea.5 O Vt F OOIf./ R u 3►itsA i' UM ! /MAtsx Iilll.Ar3 , m 3iA.1own.
t Co Name At r
O ft, 103 ft' in 1 •1 $ D dl1 n` L.
2.Well Construction Permit#: PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(le.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in
Water Supply Well: iZ1,SCREEN; ,1_' ycSzZ-s ,',N ;,i r,,„ ,,, '-tom.. .:_;<Y`. F Y , :`I r�'.'�
p FROM ft I TO I DIAMETER (SLOT SIa 1 THICKNESS I} ., `MATERIAL
❑Agricultural ❑ ici al/Public
❑Geothermal(Heating/Cooling Supply) VAcsidential Water Supply(single) ft. ft. in.
❑lndustriaVCommercial ❑Residential Water Supply(shared) .:aril- Q[i ..;10: ` :i: ;S4li : • e:14.',µ j;> '
❑Irrigation ❑Wells>100,000 GPD FROM TO MATS EMPLACEMENT METHOD&AMOUNT ,
Non-Water Supply Well: b ft. 20 ft• belk-Lbhl}v q ray 1
ty
°Monitoring ❑Recovery ft. ft. c.l
Injection Well: ft. ft.
OA4m fer Recharge ❑Groundwater Remediation '1 /cR 1xELP irapileiITe ?. ...,, � 'w
rr,:I r+ T S:z�
❑Aquifer Storage and Recovery ❑Salinity Barrier mom I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
°Experimental Technology ❑Subsidence Control ft. ft. .
❑Geothermal(Closed Loop) ❑Tracer l_! M_i • .s il;:''.didonaelieeti- '" `r t. : <.:<IOTAIIBIIECIIIMIIIII
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) DESCRIPTION error Wine• son/rock c� n etc
IMIII as0 ft• a
4.Date Well(s)Completed:'11 201)3 Well ID# i 6 ft. lO 0 ft' Err Qlt f D c
rt. ft.
5a.Well Locado '
Pt. 14 bJJ(5 !(�I M . u ,�
Facility/Owner Name Facility ID#(if applicable) ft. ft. I
I ag° A Beal./C( C1 e4) 11,7t7 y ft. R IIIIIIIIIIIIIIIIIIUIINAIIIIIIIIII
Physical Address,City,and Zip ft ft `-; 't..:-1-.1 ' --^°j`` S 1
Ala S h 7113) 3 :t,,, , �...,.-<<.y r s,, ,,,, ,- ,, a. w.m
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
3.13 WCli ii23A.,UDC hallo 3g 1S JLLUN:3c“) hS.Lergt,Catiun:
N W ,_#iaai51A (2—ao -23
6.Is(are)the well(s): Permanent or ❑Temporary Sigrla of Certified Well Contractor Date
1 By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or eNo 1SA 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#21 remarks section or on the back of this form,
23.Site diagram or additional well details:
You may use the hack of this nave to orovidr additional well construction info
construction,only 1 GW i is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach adaitional pages it necessary.
drilled: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 b V (R') Submit this GW-1 within 30 days of well completion per the following:
For maltlple wells list all depths if dlJferent(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: 0 (ft.) 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.) a.,rt...", I F14 t<,tgr n,1,.eh Nr liAoo_1 F1r;
12.Well construction method: air rbta ry 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: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2. 0 Method of test:
13b.Disinfection type: ' i Amount: 11Z 1 6
e,.,,.,nuu_1 North Laroltna Department or hnvironmentnl Ouahty-Division or Water xesources 1tev130U o-O-cu 1 b