GW1--06294_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
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��,W.rl'-1`EIk.Z.tS�S a`�.z�i':�x J:>.4.: �K� :..�.�a..�� �..�{...'a.
FROM TO DESCRIPTION r
Well Contractor Name ft. �[/ O fL
-2,�1 � ft. �t o ft. to icr
NC Well Contractor Certification Number 250:HITE 'e S1ST (for:ruini a aW411s}9)I I0ER(tfip Ifahli ` -`••<' V.4
G-r 6 c FROM TO DIAMETER�1 THICKNESS MA)TEIWL y
Y � (y(���j Jt{�� 1 oIL O ft. 1�1 ft. ( t 1 to 1 r f 5s GI:ua 1 .q
Company Name .��'��i R.�ekSi1$iG.OR;TET$A�t�.(neotGarnti`sl�lased�Tuup) [,�'
r a1J ` 0000 33 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: V ft. ft. in.
List all applicable well construction permits(i.e.UIC,Counga State,Variance,etc.)
ft. ft. in,
3.Well Use(check well use): •
31 SGREEI:1 J• _. a lY`. . Wx;.r ,,..4•Y WI t '..fi .:. f. ,._3:..* ,.: ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑pIunicipal/Public ft. ft to
❑Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) ft ft. in
Dlndustrial/Commereial ❑Residential Water Supply(shared) ;,h v x. .»,>'oz,r 4, m' `.9, • • .:s
❑Wells>100,000 GPD FROM TO MATERIAL,. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. a. ft. be �Ptkovo r-G 1j 1
Non-Water Supply Well: I)
:Monitoring ❑Recovery ft. R. r e di
Injection Well: ft'
❑Aquifer Recharge ❑Groundwater Retnediation
msA1+lU1RAXLPCYC.fi ?;,y.; ..,; .,r_r t ` y r,... :to
taliPlxt�ablel •. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Subsidence Control ft. ft.❑Experimental Technology t 3�,,�� .r L<,,...;=T
❑Tracer 20'TiRILI g°1z lGtatiac$additiu$atslieei's'sifneecssatr} r...x.
❑Geothermal(Closed Loop) FROM TO DESCRIPTION(color,hardness,soiUroek type,grain size,etc.) •
❑Other(explain under#21 Remarks)
❑Geothermal(Heating/Cooling Re )^y� �j( ® it. �C it. G��;
pp� 214 Well ID# I "'0 SO ft (0 0 ft' b� )1 r0Gk
4.Date W ell(s)Completed: ��W p���
5a Well Location: iJ'NJ��V tir Greg t O D ft, (go it- 3 P'-4 f i f-z rock
Col?), 'So A 11 ft. ft.
Facility/O Name Facility ID#(if applicable)
ft. ft. ,$ Y;�, .._'i:., a C A ;!
.13,507 ti trke Vef1/41 iv,/Vcck
�ss, ft, fa OCT 2 2 2024
Physical Address,City,and Zli Mr
D- ,;,
L]Jo
City Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:..
(if well field,one la/long is sufficient) 22.Certi cation: p
N W -P �� V1 A Date
z�I
Sigma of Certified Well Contractor
6.Is(are)the well(s): lilPermanent or ❑Temporary
By signing this form,I hereby cert that the well(s)was(were)constructed in accordance with
1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
7,Is this a repair to an existing well: ❑Yes or o of this record has been provided to de well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional 1 ell 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: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I b (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 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: a (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+J'
i/'f (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
11.Borehole diameter: ( Program,1636 MSC,Raleigh,NO27699-1636
i
12.Well construction method: Q 11 ('a t 24c.For Water Supply and O I en-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: ',` 24d. Program,mit 4d.For6
Water Wells MSC,producing
cin gover 00,000 GPD:Copy to DWR,CCPCUA
(
13a.Yield(gpm) W
Q Method of test: ld 7699-1611
13b.Disinfection type: L(.+t'` Amount:A 1 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018