GW1--06291_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information:
i
ro V. 6 6 I e+ 1d,:3'4,AEIt'rz'(51dE8:v?x,' st S F' '::. -tm?„40:.'::`vm,` (.s, '., .. e;:,
Well Contractor Name FROM TO ft. _DESCRIPTION
0:?.i( A ft. 210 ft. 3,',Joni
NC Well Contractor Certification Number , b itlirg GitiSITId(foi;mulh`cased wells)iiRTil`IERY'(if applicab`Ie)`f r.a':
C l ra di hrupir Cp, FRM �(Pott r9 ft' �� ft. f I/q in !(� Y/ li 9 iid
Company Name / g 16 1 4 CASING)RIT:IMIING'('gpotlsernyal closed.l'tinnp .,*-+cf rs r ^,)Fy e ,
2.Well Construction Permit#: g` a LI ' 1 ® FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft ln.
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS f�f MATERIAL
❑Agricultural ❑l, unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nifiesidential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) t.j i,, .g 4} „t 1.0 r, 4
❑Irrigation ❑Wells>100,000 GPD FROM TO MATE EMPLACEM&1TMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. .7 0 ft. 0,, a riaby
❑Monitoring ❑Recovery ft. ft. -Ff l,p
Injection Well: l,(((AAA
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .. , 4:.
19 5'AND/GRA;tFEL2' CKs.(1f applteablej_,5.<3•��
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer a01;DRILTINGo"[Og ai thihiirdiilo"nat shaefsYfuecessaiill :MAZZ-n'??c „s:41if
FROM TO DESCRIPT{ON(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Coolingg7- 10
Return) ❑Other(explain under#21 Remarks) 0 ft. rt. ;1�„J
4.Date Well(s)Completed: 1'' I 0 1 Well ID# 50 ft. a ft. °j"'"""tJ'.""""'���
5a.Well Location: 0 ft. icD ft. L�irit4 11 rOL)(
5C/k tit Mad)t'1 1466• ft. ft. -
Facility/Owner Name 'p �j'a/� Facility ID#(if applicable) ft. ft. .., ; ' e.. ' a; .';.,' `;
I1106 Red 81.t tr . (ayL-Q[c�, ft. 6
Physical Addr City,and Zip
ft. ft. OCT 2 d 2024
Ntis 03 (4oef ,�( �y� J u 4 a y .'S?. y' h� t„ ` 7 s ,.!. .t k ..,..>.�la�R�l`�+w+.�a:M1 Y..... ¢ �.�k"`..-'l:-ram"+.' R L�.�.ai t.t�" 3� Y.✓..,:. -t•.
r
County Parcel Identification No.(PIN) 0 4"`'`r'""-``s
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:N W - / aef
6.Is(are)the well(s)• (Permanent or ❑Temporary Signature Certified We1)51AL/
ontractor ate
` By signing this formal hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lVVo 15,4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same •
You may use the back of this page to provide additional well construction info
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: 16`�y� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1'0 (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use" f
11.Borehole diameter (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC1 27699-1636
12.Well construction method: air r'o-"art 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
f
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
kJ
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: I P
13b.Disinfection type: h+� Amount: I i fL
1 i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018