GW1--06267_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-41 For Internal Use Only:
L..Wel1.Coontractorrnformadon: y
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0 1 o D�E,y,S,�, � y�•a.�zA -f#rty�1�Y'(`' v'a%D �h� F?'y"3in4i;3 �7�'•1w i ri'
'� ti" ; '. (jt'FAY4h•=,z,5.,�,v:fi'!?k•:ePw.' ,l'5`,x`4,•,s 'Y5:'S:F•.-i:.,w,,K'1i:.•W',.:+::G.,•ti.,'e"t ".:'i.�;;
FROM TO DESCRIPTION
Well Contractor Name Aft /06 ft, �,y �p
N..• ••.•• i-y'atiiktati aitpitifni F3111ttt1 olisi 72Ek lithiiiiiipnit6iiiiii,i1.iF, ^?wt%ii;iu
61 Y +-t klr ... f lS1Af • FROM DIS ER Tr/H ._.__ ESS MATERIAL
.Company Name :U I iili51•
' eotliertiiaTbl •,�,+., ::It/ I 9� ] � lb. cASt G+3I1:1` �'� iSsed.Ioo(i)- ? �:.:�„,,
2.Well Construction Permit#: (l� !1 S 70 7 4..0 FROM TO DIAMETER _ THICKNESS MATERIAL
List all applicable well construction permils(l e.WC,County;State Variance,etc.) R. R'
3.Well Use(check well use): it. in.
'ryY>�:a 'vi,*.,"-' i i',ti --�:i '-„''`: i�:••,•ia•r.. c i,!.,.r 4-',,tV: i•
Water SupplyWell: ; ::R.tii>�i:....: -ai';ii,``.i��-��.i' `h1'- Z. --":44_F 'S—il Say'S"6«v:'c,'wsi:;,q.,s+�e':--
FROM TO DIAMETER SLO191ZE THICKNESS MATERIAL
CrnJ,rnvliiniti Ea uniei a.17Pi liu 1I it. I it. I In.
C3Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ' ft, ft
DlndustrialiCommercial °Residential Water Supply(shared) r�lB;GttOifl'I' ,:r:F_?,'."es h 0tj SI•;=;'=. v; ,.: • ;=V> ;
1. .FROM TO MATERIAL EMPLACEMENT. OD&AMOUNT
t�lrrigatian GlWells>100,000 GPD
Non-Water Supply Well: �`� R' ,`� L Y! {�✓G t
°Monitoring CReeovery R'' p' < 4 t 1 c4
Injection Well: ft, fr.
GlAquifer Recharge • °Groundwater Remediation
:?s�I9F-1.30il)1QRl;,�01C;i l`-aFio�. e1N:rk�.,,•,` '`44.;qWtrA,�.WATicSTA
C1Aauiter Storage and kecoVery uSaiinitvv Barrier 11'i nnM r TA I MATRIZT AT. r vn'rMw onn I
CiAquifer Test ❑StormwaterDrainage ft. It. .<
°Experimental Technology °Subsidence Control it.• .St.4 ! f •
°Geothermal(Closed Loop) • °Tracer i fit:itZ l`NGLO1 (attamddiiion `d:eeisifneoessdcy)::r 0.G ? t` ',~�v F, .
°Geothermal(Heating/Cooling Return °Other(explain under#21 Remarks) -
0ft' 5e ft. CI
4.Date Wells)Completed: `) DO1 2 ail Well 50 St6 Q 0 t�%f t i fed (o CASn.Well T.nration; it. ft. J
P6011. PI gr-CI5 Viiiii '' -E. ;‘, 4&... .
lity/Owner Name 4 Facility IDk.(if applicable) _. ~r '.'` ? -
4ti `b C�>� , ( t' \A aha' l,► � 115 it. `• - —, �f .4.,„3,.'
F
Physical Address,City,and Zip ft. ft. 0'O
CT Z [OZ4
IA 7 Q,1{/ I 3 a0e4 7 7/4 z'f• a7tti�'-rt.ra¢s;5,`�','"+`t' (si �k!. s"ek'i. u�t;ail tk t t�id:`�c+r i iG�F+\t�`•';
VV ' a, ,,J`J71rt -
County Parcel Identification No.(PIN) D. '.:,_'.°
Sb.Latitude and iongltude•in degreesiminutesiseconds or decimal purees: ;
Orwell fteid,orie tadtcng is sairwieui) 22.Certification:
.N VI - �'b).A e)-S2H
6.Is(are)the well(s): ®Permanent or °Temporary Signs of Certified Well Contractor Date
By signing this form,Thereby rertIfy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or flAo. I SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction 0formation and explain the nature of the of this record has been provided to the well'wirer,
repair under 4121 remarks section or on the back of this form.
23.Site diaoerram nr additional well details;
.- ._....___. -.-7_ ._......_,:ter_.:.: -:r —
.rr •• .— r•^•••-IT mg ••••.•r..,eR'7P 7:---•+•- ..... ..y••.. {.••. t.... . .w.'.. u av a waae x .wen uire
construction,only I 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: 60'v (fti) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@a 200'and 2®100)
10.Static water level below top of casing: 1-0 (ft•) 24a. For All Wells: Original form i to,Division of Water Resources (DWR),
If water level is above casing,use"+" ,�f Information Processing Unit,I617 MSIC,,Raleigh,NC 27699-1617
11.Boreholediameter• .(a_.t�_-Y,_. ..(in.; 1 7d1_+.Iron Infection Wallet t'oy to TIWR TTtrier.ro.n.d T:.-.Non C tr 1(IUC)
t'8k,r,,,—,.,...r,.w;.,., :.amian;a,.,a.u - swa+
12.Well construction method: t i! reed 24c.For Water Supply and•Opeo Loop Geothermal Return Wells:Copy to the
(i.e:auger,rotary,cable,direct push,etd.) county environmental health department of the county'where installed
. FOR WATER SUPPLY WELLS ONLY 24d.For Water Wells producing over 100,000 GPD:Copyto
p g DWR,CCPCUA
13a.Yield(gpm) ip Method of test: 1 i9 w Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: hf 11 Amount: f!I— 4
Form GW-1 North Carolina Department of Environmental Quality•Division of Water Resources 1 Revised 6-6-2018