GW1--06270_Well Construction - GW1_20241022

yr.E,L,L l> rt IKuCrIiIOIN RECORD (GW-1) For Internal Use Only: I '
1.Well Contractor Information:
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QdbIL S4`?oIYi` 1VESs rr r �� ax. s k
Well Contractor Name FROM TO . "" t a �a` ^.. f r
''') DESCRIPTION '
/% 46 1 A ft. ^'t/1 ft. I! 1,9�I� •_
NC Well Contractor Certification umber & .k adfn i` I�+7
01
ark
/Y� 1. f1 s� PuIM
,,1OURt/rY 't `N, P6 V I ` FROM TO DIAM MTE` p THICKNESS MATERIAL
Company Name /• I ft. f .y ft. I ,1 dn. I
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��( g �16. 1$u+1G,16IrTtlk ' g¢ ermslslaaetT=1'uo " r:1�, q,;+ J r 2.Well Construction Permit#: 6 W 10'I V aO ) J FROM TO DIAMETER p� ` '
List all applicable well construction permits(i.e.UIC,Counh;State, Variance,etc.) g, THICKNESS MATERIAL
ft. I in.
3.Well Use(check well use): ft ft. in. l
t Water Supply Well: 1.SCIt1;Ei`I" t�'.` ,t.r ,: c s
ttk �. .::_ ` ,.;-:.,: ,.g�:,,,��,j* Y z r _�_l.
❑AgtiCultllial FROM TO DIAMETER SLOT SIZE TRIMNESS ` MATERIAL
❑�vlunicipal/Public ft. ft. in.
['Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft in.
❑Industrial/Commercial
❑Residential Water Supply(shared) e --
❑hri aticn ..IS.:DRt)112'�'�,�� „�� ,.�..`;Y ''� k,,;� as.:<.. �, x �.� v�,4�- _!:,�.�1�,.
g ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recove 0 s. fft. . fir ht0 a(ra r ti J f
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 1miasi tOrtliVFi'.PAt i (l(appt eab[e), ' �-s, r :;= .�::-,, srt.;r3i
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage it. "ft. !
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer n. lkDR.Vl ilsl4ry(!G(airdataddittonolshiecsi€niessacy)' ...,I WM . ,i��4 ti
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness,soWroek type atom size eta)
�J/h ft.
�® g, C
4.Date Well(s)Completed: 5-17 - Well ID# 320 ft. reel
Soft. qrG �s ka le.
5a.Well Location: it ft. ,_ j • V y
a KO Cons+. 0'1a110 I340 ft. ft. .,,h .._.>, ,: .. 47- :;
Facility/Owner Name a Facility ID#(if applicable) ft. ft.
Q a 1//�1,/ ,. r nn 0 C T ? 9. 2024
V 3D r Y' cum to 0 i tv6 rcP, ft. _ ft.
Physical Address,City,and Zip lll...((( f4 i' 'v M y
WA ..,Zi:�1SfARICS,�t ..s. .tir�i.of,. rs?;.�z�'�}{�,;vd-rivi �c,;, .,� `-c..t} z`,�,vy
County J(L Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lar/long is sufficient) 22.Ce tii'ication:
N W i _ - ).
4
6.Is are the —L Si?./Is(are) well(s): (�Yermanent or ❑Temporary r_ of Certified Well Contractor ate
By signing this form,I hereby certi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: -❑Yes or 94o 1SA 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 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: r •
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land,surface: Q fa (ft.) !
For multiple wells list all depths if different(example-3@200'and 2@I00� Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
,
If water level is above casing,use"+" D (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
14
11.Borehole diameter: (
Y _(in.) ' 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a t r ro t
(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: p,� I {� 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: V ` "" Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: h+k Amount: 1 2- (19 • '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018