GW1--06300_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 I
1.Well Contractor Information: f.
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.� ti*FROM
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TO DESCRIPTION
Well Contractor Name • it aoo ft. a G 45i)'
(D-as) A ft. ft
NC Well Contractor Certification Number w15.OU:'fF;RCASINOIfoc ►p eaSetY wells)01a1PiEit`.•(tfap liiiiii) .. s a, ._.-3'°
CP
FROM TO DI��IETER THICKAIFSS MATERIALCi')!r� ���jl W�lI �� 11 O ft. [jO q ft. I ! m .,t� olivol?.er._ P '16 INNER OMIN6..DR'xTtI13 OIt;eiiitii.iii0kliiii$,luoiiI -a: ME R
Company Name (( FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: - ©e
ft. it I in.
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) in.
ft, ft
3.Well Use(check well use): '
41i'SCItEE)!t''�s.+ f iffg , M:gp-g7, .m 7;4. . ;i isY v- _.-;:c:_ .:?u,z)
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural
• •unicipalIPublic ft. ft. in
❑Geothermal(Heating/Cooling Supply) siResidential Water Supply(single) it. ft, in
❑IndustriaVCommercial ❑Residential Water Supply(shared) '� %- O� ak k d. t : >r r4kj 4, W : 3, N
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
❑ - ft. so ft. (Deurreteao 5 fa v )pt
❑Monitoring ❑Recovery ft. ft i
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 11p.U)7G , uY (3f- ¢uchliie) =.:z' -.,. .f;; .- "'- -»y.'::`Y, q i•-`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•❑Aquifer Test
❑Stormwater Drainage ft. It.
❑Experimental Technology
CI Subsidence Control ft. ft.
ff i tittli gtOO htiWidditlonai•shkef§ffneceisa`ii E .�`-�r...t f;.�:? .`:4._�.n
OGeothermal(Closed Loop) ❑Tracer •
FROM TO DESCRIPTION(color,hardness,sotUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it IS it a L�
C ^ aB-A° Well DO ( © a00 ft oa If (r f,�
4.Date Well(s)Completed: J 5a.Well Location: aim ft. 210 ft.
C tF T't2, re,t.
1 oU ,J k4 h61.i.11 f ft. ft.
Facility/Owner Name ility ID#(if applicable)
d 3-7 461 NIJ- •4SS it' )iL1J )<.- "�5 ft. f t ` L, ... i i i, : ')
Physical Address,City,and Zi I 1 2. .� s ,: 1 ,_ .its l �� ' :>.": s_c w
Na h alb- oo' 81I � �_:1 4.� xar�:n
County Parcel Identification No.(PIN) tt-;:;,,:a t,v:i-,.4,ir.,>.rYo.,rii4 scs-a
F?`t;vrerry'S;t'p
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:,
(if well field,one lat/long is sufficient) 22.Certification:
N W � 4/ A ;"?(- J
A ermanent or ❑Temporary Si tore of Certified Well Contra
Date
6.Is(are)the well(s): LLt�rP
y signing this form,Thereby certify'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well ❑Yes or 0 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 an 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:
8.For GeoprobefDPT 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: )-#3'° (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: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"• t��
t() 24b.For Injection Wells:Copy.to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh,INC 27699-1636
12.Well construction method: j 6 al7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I Method of test• .1) � '
13b.Disinfection type: kt tl, Amount: i72 I
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018