GW1--06278_Well Construction - GW1_20241022

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WELL CQNSTRUCTION RECORD (GW-1) For Internal Use Only: i '
1.Well Contractor Information: 1
6Gt.1/l/ ,r pez_ _ �` �19.�WATER ,,..'-.,,ZONES. 1.
Well Contractor Name ,y FROM TO
ft. it. DESCRIPTION
4 rtj f_ - ft. ft. 1 ,
NC Well Contracto`rJCertificati 1 1N .1.er L1'Ss0U1PEltdCASING•'(fonimii ti?caseilwells 1011) iIPIER:(if,ap'licable)l r} '••'v'f'
/ t t t )f Pavvir
e
1IDIAMETER THICKNESS M 1ATTE`RIIArL
(.--4-P't.�<J / e,' 1 v 0V —!~31 6i. FROM ft. • .j�. ft J 6,I I .5"in. S,D R I I Y v v
Company Nfine ///yyy iIl6i3NNERKCASING:ORUUB1NGr(giiiil ermal.clos"ed=loop)iV 'r 'f A; • r'`:'
f , /'!. /2) 4 ,)b/� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: f/t�' GJ{t`— v ft. ft. 1 in.
List all applicable well construction permits(i.e.UIC, ounh�,State,Variance,etc.) in
ft. ft.
3.Well Use(check well use): s si yytF err,+'h„t°_ ,,t,,...t M�� u A. .a ti3
1'7:iSCREENf L _ . F /P K
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agrictiltural
❑Municipal/Public ft. ft. 1 in.
❑Geothermal(Heating/Cooling Supply) li4Residential Water Supply(single) ft, ft. m
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) K513 GROUsivl$. ' -• %u l
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irr
Non-Water Supply Well: 0 ft. oil) ft' h e - ii;la11)G 1L.YI d- 1,2 ID Cz-!r 6
• :Monitoring ❑Recovery . ft. ft. N./
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
b19:'SAND/GRAVEL"PACK'(Ifapplicable),a - ."4'`r- EMPLACEMENT METHOD
.'
DAquifer Storage and Recovery ❑Salinity Barrier FROM ft.
ft. MATERIAL
• ❑Aquifer Test `- ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft. .
❑Geothermal(Closed Loop) ❑Tracer
F 20;DRIL'LING:LOGt(attacl s lelite"o'naltsheetslH necessary)f a i`r L- 4 ' '
FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. J ft• t 4 t
1'c-rrr y i--o►/d I )4 -c1x
1 Q.,z- 4 Well ID# it. ;I1 b5ft• G1f i ct.)1) re,
4.Date Well(s)Completed: `� `I'ft. ft. 1lkJ _
5a.Well Location: ? ft, ft. ,.
W-e Li; it 64..)1i� e ft. ft. T
Facility/Owner Name Facility ID#(if applicable) 0 r i 2 b+ 2024
`f I ail ✓e,j LI'U ft. ft. i Ir`c.7.,,._..,., .. • ,•r
Physical Address City,and pR, i t ,. "` ,
lc2 asmARKS`'�; f� d5,&,t i;-_ ,,J. NiV zX J' "-"a.
County Parcel Identification No.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) '
j_51.5" 18 N —4 f, ~l 71l'1 W 4 ti �‘f )a 6 -. .�-
Signature of Certified Well Contract�if D --ate
6.IS(are)the well(s): *Permanent or ❑Temporary
By signing this form,!hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 6No 15.4 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 n,Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in RemarksBox).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: h� (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2()a 100`) I
( 24a. For All Wells: Original form to Division of Water Resources (DWR),
ft
10.Static water level below top of casing: p ') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
' 1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
4- I
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: )^6j -)' Y 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: , pemtit Program,]61ll MSC;oucinRaletgh,over
N 020,000 6PD:Copy to DWR,CCPCUA
13a.Yield(gpm) I-4- Method of test: -''--i r
^ '^ 1t
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13b.Disinfection type: L .AD)'i )16 Amount: r L'_-
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-- - 'M,..),rogue.nenartment of Environmental Quality-Division of Water Resources Revised 6-6-2011