GW1--04570_Well Construction - GW1_20240731

WELL 1;UPIS 1 KU L.I IU1' K11,l,UKII Kr VY-11 ror Internal Use Only:
1.Well Contractor Information:Sa50 n NO I az- ;14 Sr czor1
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FROM TO DESCRIPTION
Wcll Contractor Name
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NC Well Contractor CertificationNu �-,
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2.Well Construction Permit#: L��- O �/b 1D -FROM TO IF DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.) It, ft. to.
3.Well Use(check well use): ft' ft' in.
Water Supply Well: :=fi?:;fl( >#N .s :>: .�;6f :w_{ ." ..'.:: r �. :rr fr'•- .;. r3•.•.:,j;.. .•,«s ._.';;
FROM TO
ft DIAMETER SLOT SIZE THICKNESS MATERIAL
❑^Agricultural ❑ wnicipal/Public it• in.
LiP-._.1;....-.rt1-_.:.-_ln-_,:_..('.171.A AJ..- 711V.....-C..7.1:...: :;':!. ( .u.
❑Industrial)Commercial ❑Residential Water Supply(shared) :f�Y[y Rori ,I t>t""+ ,:4
a IN.V .✓:�i, .: *.. �.r,..�.v�lh;�- 4.�1.�NrS-.F�..a.. ;g .;/:
❑Irrigation ❑Wells>100,000 GPO FROM TO , MA M METROD&AMOUNT
Non-Water Supply Well: 0 it aQ C l4 i (AU'
❑Monitoring ❑Recovery ft. ft. ��111
Injection Well:
It. rt.
❑Aquifer Recharge ❑Groundwater Remediation
't::19 SAND/GRAVEL_PA'CK(If.applicable)
°Aquifer Storage and Recovery ❑Salinity Barrier FROM ( TO MATERIAL EMPLACEMENT METHOD
u..yu.. .w. ft. i ft.o......--:_..._1-.=..3e 7.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) °Tracer ,10 i eYalidtttc ti'4 esdti T;) I: ;r' ,.:".= '•
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,bantam,antllrock type,eats sine,eta)
^2 1 r [ 0ft' (ooft' GIQ
4.Date Well(s)Completed:�2 I 1 et✓ Well ID# O+ ✓o r o o a• f LI D D' q rt /1t f t, rb C.k
Sa.Well Location: ft. it.
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PLI4 6I�r5. [c. ft. ft ( t . .. ,..
Facility/Owner Name FacilitylD#(ifapplicable) ft. R. JUL 3 292.
11/5 (3ear Run In, tt. It.
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Physi Address.City,and Zip ft. ft. . If.¢.; ,..,- >.-• ..,a
City Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if well field,one lat/long is sufficient) 22.Certification: tt
N R' g1 1L - I1- ?3
6.Is(are)the well(s): ii rmanent or OTemporary Si of Certified Well Contractor Date
By signing this form,1 hereby centfy that Me wells)WOW(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or SC 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out blown 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 into
constnictipn,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'[ 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths!f different(example-3®100''and 1®100')
10.Static water level below top of casing: d�0 (fL) 24a. For All Wells: Original form to Division of'Water Resources (DWR),
Information Prot sing Unit,1617 MSC,Raleigh,NC 27699-1617
If inter level is above casing use"+
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
II.Borehole diameter: (In) Program,1636 MSC,Raleigh,NC 27699-1636
11 Well ennafi.nrtinn methndr ni_ .r _• '..__c ,.. a n- r n .. - 1 D Mr Wnit.•! +.,rn(lad
(i.e.auger,rotary,cable,direct push,etc.) Or r rotor/ county environmental gealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) . Method of test: blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: (4 fin Amount:__,j / lb -
lll 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018