GW1--06233_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:c)601e,
t yyy { ;t� F� �aZ'!i,''n.Li�41 is( i ti `g 40 1 Y M fa i *;C ,, s" V-;xY`•
Well Contractor Name FROM TO DESCRIPTION
"3- ---14( •�{I pri
ft. ft. "��(.I 41 ,
NC Well Contractor edifice on Number , n'x�
{ W ��n ..a0 �rRst �rsbiuttYnssispfrO, :
•nil al Pb�{ 1 41 1 r0-1�t' e,0 FROM TO DIAM/ ln.
"THICKNESS MATERIAL
IL 2.5 ft.pany4reir ii 16:104 id0 arir . �;
2.Well Construction Permit#: 19.51 V d6� FROM TO DIAMETER THICKNESS MATERIAL
ft. ft.
Vedette.
List all applicable well construction permits(i.e.111C,County.State,Vedette.etc.) • In.
3.Well Use(cheek well use): ft' {°'
Water Supply Well: 014150Ittgai'a i4 a ; 1 N' s, ^ ?.;;,IWRA,;-.'.•u u.�ry c;,"i': °tt, .t:.:til :•
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural ❑ unicipal/Public ft. . in.' •
❑Geothermal(Heating/Cooling Supply) R ft
esidential Water Supply(single) ft. it. tn.
❑Industrial/Commercial ❑Residential Water Supply(shared) _ - ,... �•.
:;�•i�r'.';11�Q�'�-.fib°S.'.a k4sJ�-•Ct�l{=�r .{.�,'ai�;;+,•, ..,.='�tYi4.�iY'h?l.i;,.',.°7�''�'eit�.*.;��r`%!�'r.&.7�'ti\:a�• t
❑Irrigation OWells>100,000 GPD FROM FROM TO MATERIAL , EMPLACEMENT METHOD r4 AMOUNT
Non-Water Supply Well: 0 ft' 2.0 ft. b„e 4- r� -�),7 rAt
❑Monitoring ❑Recovery ft. tt ( / ef
Injection Well: ft. Ct
❑Aquifer Recharge ❑Groundwater Remediation .yy,, x
ah >rs lU:>e cilb Y,df,'4 S:: ,1trr'c `-•';e::v':ti"ri ..:iY;
ClAquifer Storage and Recovery ❑Salmi Barrier F MATERIAL
t ��.` `` � EMENTM :F.
qm torag cry tY FROM TO MATERIAL EMPLACEME�ITMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. ,
❑Geothermal(Closed Loop) ❑Tracer 'g ]"- Olt,'iitYilithY a ai iiCi(irlakli r-. 'i' `S•;,4. •k_s* ;,
❑Qeothetmal eating/Cooling Return) ❑Other(explain under#2I Remarks) FROM 7 t " SCRIPTION(color,hardness,so1Vrock type,Vet am ere)
4.Date Well(s)Completed: �9' 30'44 Well Ito An ft. „ e 01L f� 14 rtg two C) .
Sa.Well Location:
ft. ft. ,/
- Sek .. e` 11 PIS. ft. ft. ,..L.:.:::i..'{...r .V z.,1_.
Facility/Owner Name Facility ID#(if applicable) ft. ft. T Sii
1711 �^ :�0ii tr a c ft. ft. C I �G2n
_
Physical Address,City,and Zip ft. ft. lr�`.�;F;%: `r s SJ .I
G1-d N ,t l 1 }*vrl;:'•Rnwataxx`zaig'k.?:•:* l.'.ti.w;> °c ry g'.o',xral am.5`M .Yli""::'.1L1 v?i s
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatllong is sufficient) 22.Certification:
N W ,_.,. a.- - 2g
6.Is(are)the well(s): iermanent or ❑Temporary Si_.-.. of Certified Well 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: DYes or ..4o ISA NCAC 02C.0100 or 15A NCAC OZC:0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infbrvnatlon and explain the nature of the of this record has been provided to the well owner.
repair under 4121 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-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/ (f') Submit this GW-1 within 30 days of well completion per the following:
For mrdtiple wells list all depths ifdiifferent(example-3®200'and 2@i00')
Static water below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10. tr level is aboverlevelb casing,use„p Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If / 1 ,f s�
11.Borehole diameter: ( ,Ii1 (in) • 24b.For Injection Wells:Copy to DWR,Underground Injection Control(ICIC)
Program, MSC,Raleigh,NC i 7699-1636
12.Well construction method: �,� ��/" 24e.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:Copyto D
(� �1 R ' DWR,•CCPCUA
13a.Yield(gpm) f Method of test: UV Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: !J l 1 a l Amount: 1 I'S'
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