GW1--06222_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1
1.Well Contractor Informs n:
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Well Contractor Name FROM TO DESCRIPTION _
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NC Well Contractor Certification Number , ri„ ,- ,
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G^ aC_/py pool ti u j j e FROM To DIA,rs tr t •ixtc.KraZzi ,iu kitIAL �, a '
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ft. I( to 014.101 `Company Name 1 (I ,',1(;;) ILC:M111fs)DI 1 11y.Q; eotliiiiii '.•-c ose. 7aiilile `', .+�,.; '�'-'•:- �':;:
2.Well Construction Permit#: _ FROM 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): R' In'
T1 CRBF.;+N::.'3:Mt+' fiZf(a'g4Wt s+`5".KI-" -Y4.Vsf,:ate°l.,rfggi;- tit."s.%r, 5 h_',
l Water Supply Well:
FROM TO DIAMETER SLOT SIZE 1 THICKNESS MATERIAL
❑Agricultural Dfunicipal/Public g, ft, In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. In:
Olndustrial/Commercial ❑Residential Water Supply(shared) „ sy, t rt-.;�� -W-� .,� r s ,,,;?,, ., x , -K
. S7.fl,�Q�`��N,r.':'f-.�.t<M.,�x�ycw (3-Kk.r,�4-,E.t-_.,L,y�`4"f..x,:s S`,.-1+.:�....I'd Y:
❑htigation ❑Wells>100,000 GPI) PROM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt' 3.0 f' iotsio yl t-QL /non is
❑Monitoring ❑Recovery • ft. ft.
Injection Well:
ft. ft.
DAquiferRecharge OGroundwater Remediation y k 4 3 . . VI
TVIe
❑Aquifer Storage and Recovery OSalinity Barrier FROM ( TO T MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage fa ft '
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) • DTracer u11010131L7tttf.. rid xtracraddiilionnls a iirii`nacaar$7,"?'?W+ , ,.Omm ,
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION{color,hardness,soil/rock type°rain sQe eta)
0B r� ft. 3S ft. c 9
4.Date Well(s)Completed: P �� `i Well ID# 3.' n• 2.14 D �t t r o c Jc
5a.Well Location: tltl ft. tr. LI
!�n .+t A tk l I.e, rr_ _ft, ��---
ft. ft ;LT, y i-i:•==
Facility/Owner Name Facility]DH(if applicable) ..--� +1 !L-,5
�,L.)�.3O W 1{y 1 t t-� 'PrA f'M In 1,(a ' � D tt. , ft: 111• 1 9 i 7096
Physical Address,City,and Zip 1 ft. ft
J-®9" f tl`S 9 a a. 'l. ✓};x 4 �iyl ':t rii aiY 'Cf u•� 'ice ^. k _:
F2$ti'�1�S4,o-,_.tt,'nc!•�..,F,:.-in"�N..S'��•rr.._�:..rt�..";.sS?.r a.,,�.al.>V.z 3�•�,:.'�'+�x1:�?r�".�a�-�=.:
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt Lola,uuc itiVI tiig a stif isiQat) 22:certification:
N W a��1 ft 6, g-L(
6.Is(are)the well(s): t�Permanent or DTemporary Si i of Certified ell 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 i No 1SA NCAC 02C.0I00 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:
P.r.._17 .Trt:a.,M PT,«r!....,a T..,,.,r•.,...,,,-...,.,Ilirpl.k.r.,..a..�.r......., 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.TotaI well depth below land surface: a 4 a (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3Qa 200'and 2Q100)
10.Static water level below top of casing: ( ) 24a. For All Wells: Original foim to Division of Water Resources (DWR),
ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+�'
11.Borehole diameter (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Provram;1616 MSC,Raleigh;NC(7699-1636
12.Well construction method: rr. roil try • 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
13a.Yield(gpm) i Method of test: 1t0� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: h_$ �)_ V I I T i'� Amount: 'y ! I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6.2018