GW1--06269_Well Construction - GW1_20241022

WM./L CAl11Vb'1'.1KUCl'1ONRECORD (GW-1) For Internal Use Only: ; '
1.Well Contractor Information: I
o V I Pcc 1�° iri`4,•VA'I'ER':ZONE$ i ;g r5 a I
Well Contractor Name FROM TO "' s;__"�' `.'`...; °
C� ( DESCRIPTION ry
� "� 1 ft. flu: j j
(:),, 1
ft. ` it d I 1 NC Well Contractor Certificationcumber
' 5'401/TISR CASING(CnWiiii"lti cased ifellgO 1 INETE(if-11E"able} ::. �°6rtt \I a FROST TO `z'() , V)ell Cp. DL4 R THICKNESS MATERIAL
Company Name f ft. ft.
in,
( � 1 pile.,
,_ p``� k:1.6:N NER D;ASING:MTCIBIA ETER-ermal'.clas THICKNESS
r,. ., Qr,3 a C ',:�;:..2.Well Construction Permit#: 1Y1� ! +' FROM TO DIAMETER TKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. I j in.
3.Well Use(check well use): ft. ft. in.
'Water Supply Well: .i7 SSCREEI-:::,fig . -i— , :iMr r_.y:_.:. K r , x
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft. ft. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
1$.GROU1 :-,. �,e, ?z, stk Z.'y;.r ,,,:s_"r m ,.:nt i %.,, :t;t.t
❑Irrigation i ❑Wells>100,000 GPD FROM TO MATE E,iVIPLACEMENT SIETHOD&AMOUNT;
Non-Water Supply Well: 0 h, l o ft h Aito❑Monitoring ❑Recove dirt/ 4
n ft. ft. ci
Injection Well:
❑A uifer Recharge ft. ft. I,
q ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier u19-4-8AVD/GItA• Eti,1"AC16':(if apiiil sabre) ;,,;�s x i A *�t
ryEMq ME. i_...7,- C�..,et
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ;3'OriD1 LZiNG;LOt (attaebaddittonnlsheefafif"nines"sd'y)z 'fir;` _ ..;x z<. '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness,soil/rock type grain size,etc.)
01 n' IP ft •
-gyp ��t
4.Date Well(s)Completed: +1 I a Wel1ID# g ft• • OO ft. rah(k1 �-to C
5a.`Well Location: r ft. ft, -
{ vaet. M4 irs l to h ft. ft. t__. ' -
Facility/Owner Name FacilityID# if a - "-�_
- et v �1 reek v e vvJl4'►(I 1- 15�� fc. fr. 0(T .r, d 2024
Physical dress,City,and Zip ft. ft. 11 `.;; ,.�
.2MEN ARKS"-g x......` = t`L i:'....,t. et t?: -�+''�V:, ,.nvtV..t t ..r`
County - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:ti
N W /a'ca' ( t4tii
d�y
4
6.Is(are)the well(s): tiPermanent or ❑Temporary Sign cure of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or iiisio 15A NCAC 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.
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
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: r� (ft.) I
For multiple wells list all depths ifdifferent(example-3®200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to"Division of Water Resources (DWR),
If water level is above casing,use'+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
// 24b.For Injection Wells: Co to DWR,Underground Injection Control
11.Borehole diameter: {p (in.) gr j (IUC)
�r Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a1 r f 1-a ry
(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 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: b row Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1 I1-k Amount: 1 I 2 1.6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018