GW1--06268_Well Construction - GW1_20241022

WELL CUi'5.1RUC:'11O1N1 RECORD (GW-1) ForIntemal Use Only: ; '
1.Well-Contractor Informatio
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Well Contractor Name FROM i TO AESCRIPTION
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Ho ft. g_ Igipjy1
NC Well Contractor Certificatio Numberft' ft' JJf JD
'rl;C�, }�}(�p�1`Dt:CTIVt.'r`'rfnN�4ifuYTn-'�earF�:+:&�ll o:•.Y.'j1.%n3irhT et_=:ws:.. ,.,;,,
��9 r1!i L L),eli Nittle • FROM TO DIA�iZETER THICKNESS MATERIAL'
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y ! R. O ft. r 11 rt in. „� (�Company Name J 4� I "t 1
�h� �j`� : kilMEI i,WaiNdt 11'IOBIl`1( {deotl(eiri ia`xclfised ltuopls„ii%„� s` #,t G.� x �'
2.Well Construction Permit kit) ` I 114 7 0 M P"V®�• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UM,County,State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft. ft in.
Water Supply Well: :f7i>SGfLELPlkcq^4, L f l Nai.: is< �...�.�r, a �� r 14�: It s YS�'ai ..SS
FROM TO DIAMETER j SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑ unicipal/Public ft. ft. Ie.
❑Geothermal(Heating/Cooling Supply) fesidential Water Supply(single)
ft, it. !n:
ClIndustn Commercial :Residential Water Supply(shared) x V ,. . , $2 ,- . 7
❑hzi anon 18f�itOTITz....w ,,.__F,t:. _�g., .s,�.»�,��..� <„ak.. ..:�..:-:..r�rG..:�..t� {:.�<
g t lWells>100,000 GPD FROM TO MAT RIB EIVIPLACEsMENT METHOD&AMOUNT
Non-Water Supply Well: b ft ^10 ft. ke . N 1.. { p -�.�f
:Monitoring CORecovery ft q' ft. , rr J A
Injection Well: '1 I�
:Aquifer Recharge ❑Groundwater Remediation
19:0 1D%GItliV:Ia it'-�1r. p�of O "iREVA ,*Igi rslUsi4 ,q i OAquifer Storage and Recovery C1Salinity Barrier FROM 1 TO i MATFAT'r 1 ---
❑Aquifer Test DStortnwater Drainage ft ft. —_�_..._- ^���
:Experimental Technology OSubsidence Control 1, ft. ft. .
:Geothermal(Closed ❑Tracer ,.
Loop) .24kDRILLIFICI OafitCac ilOitld6a ikeit§1f-nece'setni "- 1Wictixw ig t f31 .
❑Geothermal(Heating/Cooling etum CDOther(explain under#21 Remarks) FR°M TO DESCRIPTION(color,hardness,solllrock type,:rain size,etc.)
to ft. 6D ft. Gl a
4.Date Well(s)Completed:a- 3.3 , 4 Well C,D ftCoo iY. 9 rt. /ti) iroe..
k
5a.Well Location: ft. ft V
Ro IA
Faci 4.1 �
illity/OwneerName Rill/1(01E1a 6pui4ug Facility ID#(if applicabl ft. ft F"; -` --
fur
Physical Address,City,' d Zip ' ft. ft. U L i ..s ti 2024
!IV k`_ <i 2 tE {i d '-.- °,'i; r a a t, ' '`+, ;3.�f.•t � s,:_�• "-.Y.'.
County Parcel Identification No '......_.... ..,: __.. •. a ;:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well f--'a, __, - .7....-.:_.'.......• I
22.Certification: g '
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6.Is(are)the well(s): 1 ermanent or ❑Temporary Si e of Certifi Well Contractor Date
By signing this form,I hereby cert�that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 1SANCAC 02C.0100 or 15A 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. I`
23.Site diagram or additional well details:
8.For t iennrnhe/DPT nr rinead-T nn,,lane."n«..,nl Zsr.n.L-_�.__.a Van may ilea f1,,,t...n1..,r at.:-�,,... a A. ,r•.• ., ...
.--Q-..-.....uv ..- t-•o_a-.................uuvuW .1W1 Y ia,,,: tivii o
construction,only 1 OW I 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: 00 ft,
For multiple wells list all depths if different(example-3 00'and2QI00) '( ) Submit this GW-1 within 30 days of well completion per the following:
10.Stade water level below top of casing: g-Q ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+4 ( ) Information Processing Unit,1617 MSC,(Raleigh,NC 27699-1617
11.Borehole diameter: (0 /Lt (In.) 24b,For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
PT.....ir., tc•-fA roe. n_t_ _.. +.., .-.-
12.Well construction method: "l I r p try
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop'Geothermal Return Wells:Copy to the
county environmental health department of the county where ins ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: b f(� Permit Program,1611 MSC,Raleigh,NC;27699-1611
13b.Disinfection type: jf1+ 1/1 Amount: ((1.. 1.10 _
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018