GW1--06229_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: • I
1.Well Contractor Information: f
ems,. '� - ` z.4., .�.`,_ r,_ 1`.R.,x.A0/�:z-�..5>, `: f;V
ty� Pool FRl �NIIsTt-lOblEb`. <E
Orp r 1FROM To nEscRlPTTox
AWell Contractor Name ft. ��7 ft. Qj p
NC Well Contra or Certification umber , •'a15 OTJTER:CiY811!TG(fomiriiilt-inteils':�Yfi11s)bli=;L1Ni R•((fnp Ucabfe
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t FROM TO DL4�IETER ( THICKNESS MATERIAL
N�_ N A ft O ft.
t I q in I o I 0 r"
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FROM TO DIAMETER THICKNESS MATERIAL. `A
2.Well Construction Permit#: ��� a�� '^ 0 0`/ ) 0 it. �0 ft. d,� in. p�r� �-��
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.
ft. ft. in.
3.Well Use(check well use): �f s Y v'
�7"SCREEN 'y,..:�, z,.,-; Y'�.",phi N+.. ..r•' ,, .�s.,T�:;,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural n�.
❑runicipal/Public ft. R. in
❑Geothermal(Heating/Cooling Supply)
l9Residential Water Supply(single) ft. ft. in'
❑Industrial/Coinmercial ❑Residential Water Supply(shared) .106,gQUTf„s ':k2,zoy`a- =h.'mtwt s•fi t' °W.M```. `" ,: a"`S
❑Wells>100,000 GPD FROM TO MA _� E,MPLACEM T ETHOD&AMOUNT
❑brit ation p ft JLL► ft. tied ia { aIP
Non-Water Supply Well: 1'
❑Monitoring ❑Recovery ft. ft. I i
Injection Well: ft. ft
:Aquifer Recharge ❑Groundwater Remediation tickle °gipili G.':.•'--=Vy5 `'• :t `+ s-'"
19:BAiY)DPGRA( PACKfifal!R }, .
❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Storage and Recovery ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
❑Subsidence Control ft. ft.
❑Experimental Technology � � 5 �� `f;,....
❑Geothermal(Closed Loop) OTracer `atf:"D11ittINGIb'G(attachadditWa sheets•f'necissiiiIi
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling etum ❑Other(explain under•#21 Remarks) ® ft. ft. G` 0.
Well ID# ft SO ft cord 1.1ei rock
4.Date Well(s)Completed: 3 a � ft. ft. !
5a.'Well Location: • ft. R.
Si'Aisqrt V eAl'h et5,
Facility ID#(if applicable)
ft. ft. �' . ,-.
FacilitylOwnerNameTp ft. •t<. '�._.. ., •
3oS "� . 4 Lifs ri. Fqi ft.
1 ft. I. U� I 2 1 2024
PhysitI+ot •Address,IA •y,and Zip , 8 ' rx .' - a,��, '.. "ksc N-� ? YY_ ,:ii.
y,23,.:12EMAKTCS;"r,.., �.. . ,,ttyy
vet
S.
s-
County Parcel Identification No.(PIN) : -`^L
1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:. 22.Cer ficatio
(if well field,one lat/long is sufficient) In j. .�
N W a. Y Jjas �4
t.S
Y D
Signe of Ce • e.Well Contra r
6.Is(are)the well(s): ermanent or OTemporary
By s ing 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 v1Vo 15A NCAC 02C.0100 or 15,4 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 iwell details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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: 2' (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 2Q100')
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"+'
�; `f 4
(in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
t
12.Well construction method: tr d ar 24c.For Water Supply and Olpen-Loop Geothermal Return Wells:Copy to the
(ie.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
�,Q Permit Program,1611 MSC,Rlaleigh,NC 27699-1611
13a.Yield(gpm) 10 Method of testk.
: pp
13b.Disinfection type:__� 1
i-b Amount: 1- 4
I '
Revised 6-6-2018
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources