GW1--06266_Well Construction - GW1_20241022

WELL CUINS'1'RUCTION RECORD (GW-1) For Internal Use Only: ! , '
1.Well Contractor Information:
(TJ Ae �1� ,
�/ z.vx..ERtt)NES .?4 t, ,143,&5Li4 o M .3;;,i g4, v.r:..f ,..i .,:lw
Well Contractor Name FROM TO DESCRIPTION
2ada( A ft0 ft Bo i
ft. fr. F
NC Well Contractor Certification Number
1I rk5: /UTERO SINGliformulhaiicliltells) )R•I`liBi �(tfapp7icuSiel r• su s
��' - Pt7ble,'
FROM TO D E EA THICKNESS MATERLIL
ft ft. I in
Company Name � ��,++ S,f�
16 VNERC.ASTLIVOR_iFUS ..0aliArm"st closed,Itfdd}^,.� ii
`: ..x ;ll i2.Well Construction Permit#: lW 11 s5 644 r atFROM TO DIAMETER THICKNESS ERIAL
List all applicable well construction permits(i.e.UIC,Count};State,Variance,etc.) ft, ft, I i in.
3.Well Use(check well use): it, ft. in.
Water Supply Well: nI7t.SCREEI :;;r t;I:W`.a:a ci r .,1 i ' lg i ..W >'
OA Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 01Residential Water Supply(single) ft, ft. - in.—
OIndustrial/Commercial OResidential Water Supply(shared) 18:G1iDilT 4 as z k 4
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL� e' EMPLACEMENT(METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ` r� ft. Cl, ut}ut;t1 LJ d( 1
OMonitoring ❑Recovery ft. it. flllAt _
Injection Well:
it, ft.❑A uifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery 0 Salini Barrier ..19.SztNA7CRAVEL PAi I((if.applic bte), "';�.;ti, i ,, x, , „_
�' FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft. —
❑Experimental Technology ❑Subsidence Control ft. ft.
+
0 Geothermal(Closed Loop) OTracer 1 I.,IiRILL1i+161t3G(afiac enh b;add►til`shicet§ifneces acyl` 3 ;5,
,
❑Geothermal(Heating/Cooling Re ) ❑Other(explain under#21 Remarks) gtWi
FROM TO DESCRIPTION(color,hardness,soli rock type,grain size,eta)
0
ft. 30, R 6C�Yt
• 4.Date Well(s)Completed:.7 1 We Well ID# C3 ft. ft.
5a.W ll Location: 5e, ft. 71-0ft _ ...1I 4-� rock.
tWirIS 144(€, ft. ft
Facility/Owner Name Fa ID#(if applicable) ft. ft. EE
ibt)'1 4 u k 6w4 . ft ft r -- s' .;;d..:1
Physical Address,Address,City,and Zip �h/�'/ p �f g� ft ft.
I �G7R
4 k`C �/IN 1 f ! a ;X3%REM KRI{5-,:e :_:, ., .x._.> 1fs.:u:— 4 a.R4, rLY _ :.:..,a
County Parcel Identification No.(PIN) [;,'4.....,, ,� •' •°•`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W Si � r' $i A � ' 1 lut
-
6.Is(are the well(s): ermanent or ❑ e of Certifled Well Contractor Date
() T mporary
signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 1SA NCAC 02C.0100 or ISA 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 4121 remarks section or on the back of this form.
23.Site diagram or additional well 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
constructipn,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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9..2 0 (ft.) ! I
For multiple wells list all depths if different ent(example-3@Z00'and 2(a�100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: V (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'/
11.Borehole diameter: e' (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
_ / Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a (r �/ a 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) Method of test:
k 61)J Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: G't Amount: it►
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources : Revised 6-6-2018