GW1--06302_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: - '
1.Well Contractor Information:
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��� ��� FROM TO DESCRIPTION
Well Contractor Name ft. .�tt. ! j�rn
NC Weft Contractor Certification Number �rd.:ic.W.Ntsa a:�,' ner+_►o r..tiv 'o':vi_rl:::ti,::�bra) r„ t
�r �1(�} ,D99D cts.D'i��1t ,,,r- rY C�!'X I rr /LIl 4 ul� FROM TO DIAMETER'!n. THICKNESS r MATERI,LPbo 0 `� cr I a �r(2,
CompanyName _ ; c: l: iitisibll;TtttaleotJiesnatclus4 ';7udp7., 't:.,% �"�r .;,_'�?
2.Well Construction Permit#: " ' 00 F 151 FROM TO DIMETER Tess MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Vart etc.)
ft. n la,
a
ft. ft in.
3.Well Use(check well use): 1,"FSR a t 0 4' w W Iy f,w ' y
I Water,Suppiv Well: FROM s TO DIAZ.IETER SLOT Fun. TRICTO SS MATE.'ritL
I
❑Agricultural - ❑VunicipaUPtiblic 11 ft. , it • mi.1 ( - F
❑Geothermal(Heating/Cooling Supply) rl Residential Water Supply(single) ft. ft. In: ,
❑IndustrialCommercial CiResidential Water Supply(shared) =r1 Ii illTia> ,, s ..: rigs?,s ti t,.: `<i.; ,;.s O4W.:',.? `e`-`"AO:•. `i..L E=i
❑Irrigation ❑Wells>100,000OPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 10 ft' +01i'r!S j r \,.71
❑Monitoring ❑Recovery ft. ft. -7,-1 i eel
Injection Well: ' ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation . F is.. `r... s :; `.
.Itl A1voiwa.utea ittttt spttiisable) r
❑Aquifer Storage and Recovery ❑Salinity Barrier I FROM I TO (. MATERIAL I EMPLACEMENT METHOD
❑A9 uifer Test ❑Stormwater Drainage ft. i ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 2,ll:Tlla"['11 T;;t €aimd add ttou`s.'1"slree iti eer:ssa trAO.W ..4sf a + t'
FROM TO DESCRIPTION(color,hardness,saillrock type,grain stye,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it. 1 F .. , ,
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4.Date Well(s)Completed:3 li a"'1 Well ID# j co n• / oft' b tip'w n ebe-k
Sa.We llZncation: / 0,"' . � t: ' q a a rt e, o��
'rod t /Aar ur n ; t.. F tt. , ,,J
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Facility/Owner Name Facility.ID#(if applicable) ft. R.
i3? 1. NAY' ic$' a Atlid1,...4.2s 7651 i . it (�t: i - ,.
Physical pAddress,City,and Sr r� boil) pq iL ft. it . _ ?'r ifsy
Y'�d'IS n 2_736`ro Yl +vs10 .. ,Rlt s'..'�''��'i n_.:.`:RicNwNnt.St,`.'A'_AiiAi <�' RAW,V'., i...-{'.'� : ..z
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(ifwell field,one lat/long is sufficient) 22.Certification: A i #
g `61A 3-fef.7711
6.Is(are)the well(s): "Permanent or ❑Temporary Si of Certified Well Contractor Date
By signing this form,I hereby cerbfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IfiNo 1SA NCAC 02C.0100 or ISA 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.
.rglair under till remarks section or on the back of this form. 23.Site tliagrisist Or tiiltaitiviltii weft idetaal6:
You may use the back of this nave to provide additional well construction info
o.cut vevpivu.II i w C...-,i=.uw�a vev.i,vs a.n:n..=ui -iait K,s:e,, -1-
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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: ! g I. 2_4.,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - T (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2Q100)
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"+""
1 I1 Li .St(in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control((WC)
11•Borehole diameter: ptcrcatrt',1416MSl Raleigh Nf:7.7699-1616
12.Well construction method: ctir total 24c.For Water Supply and O I en-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,directpush,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
,�� f ail
6 Permit Program,1611 MSC,Raleigh,NC 27699-1611
--13a.Yield(gpm) '�" Method of test: IAA
13b.Disinfection type: hL k Amount: f 1 i J
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018