GW1--04621_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
`�
yFROM TO DESCRIPTION
Well ContractorNa>`i'e ft. ft.
i(O [P A rt. ft.
NC Well Contractor Certification Number L,x.5;;Q,ell •4l"ai'•:I-.,'.o e f '''/ "0)t V '0 til t I'R+OtO ' able) • ••.
/ FROM TO DIAMETER
THICKNESS MATERIAL
("4
jYt S //(/�! �1.( m io 6,)
L ) ft. ' )j. ft. 4,1:2 in. 6Vg,zi I"GCom an Nellie rf ;1t c a"!!',q:II ltiranirajapreigUala, .4
2.Well Construction Permit#: W J/ -4 v 1 Co i FROM To DIAMETER THICKNESS MATERIAL.
CCC666
List all applicable well construction permits(i.e.U/C, unty.State, Variance,etc.) R. ft. in.
ft. ft. in.
3.Well Use(check well use): PleteRSEgtaare4RFWAtaifeWITRIVANA m
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic It. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt, ft. in.
❑lndustrial/Commercial 0 Residential Water Supply(shared) mi y s w ', m.,,t 'Y�,,c, 0 ?fix,f1 4 � "�$ ':
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ei rt. bon;n 1 te- IQD Gl.)"e-01' 13 l QA
❑Monitoring ❑Recovery ft. ft.
�JJ
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation r tea:,< f I
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage R• it.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Tracer t20 D• Iiidit i:.:i.at•:.g �r A 1V�'9� � �Zti, 44 a�<>.
❑Geothermal(Closed Loop) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. )it I
/ 01%)-� r a-t S t d7 G Aay4.Date Well(s)Completed:7`�-`�,41 Well ID# I I s b' 46Sft. r Q-VCI e, i , `
ft. ft l S
5a.Well Location: i 1
W1 ) 6n ft.
,,) 5 ( ,I
a Y`P_b n n Gt- ft. ft.
Facility/Owner Name / y Facility ID#(if applicable)
ft.
I 1 5- �t/rJl t� . fit i.
ft. i. ..1•.
Physical Address,City,and Zip
l\/t 1 ' g 1V0 ¢; _ '^,.3.�"`xc ,t:xP�}'"4Y.,'"t=
tJY c I�a��_
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:
Signature Certified Well Contractor Date
6.Is(are)the well(s): ItiPermanent or OTemporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15,4 NCAC 02C.0100 or 1 SA 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-I 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
J�
9.Total well depth below land surface: I D (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@l00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Q (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: 6 /4 (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: )4 61;-r 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Qi r
I_/ t/U
13b.Disinfection type: 6- 0 rt i Yl C''.- Amount: ei u_ ri /� y� /
/ r i I i 1.. 11 1 ✓NA it t 1 " i f).__ d