GW1--06308_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-ll For Internal Use Only:
1.Well Contra{ccttor Inffpo/r�mation::'To argagmoungimmovegmematzwomsgmmimomm
FROM TO DESCRIPTION
Well Contractor Name ft. J ft l� 1
pft. ! v ft. ! j 1 i•
NC Well Contract r Certi catio Number t:ii OU irlt`Cz15IlYS(for m'ulh-ca3efilvells)> fait NEIt:itei ucalile) ,. :,-,s..-,a
ea r iit
FROM TO DIAMETER in MATERIAL
(� V4 4 ft. ft 6, IA
Company Name .t1t 5I1`INER CASING'FOR` ftlfli ( eofhme e l clesetP ToiitiV F:> .: .y' >M."ir``'
2.Well Construction Permit#: '')—C)171 " i 1 ci FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count,State,Variance,etc.) ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
.ii7,;SCREM,of ... '2'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL •
❑Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft, ft. in.
OIndustrial/Cotmnercial ❑Residential Water Supply(shared) sRifitt t t-tfr .:,, .,. ,4m aim ..Y.,='--.v<<, 3..i n" .,-.`-- .' ,T:t:4:4wam
°irrigation ❑Wells>100,000 GPD FROM TOy MATERIALR i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft ef-0 fn bo`'7�v11ft ju"at!
❑Monitoring ❑Recovery ft. ft.
fl ll'het
Injection Well: ft. ft.
Recharge
OA uifer Rec ❑Groundwater Remediation 1 z 41 t
q g L4: Aisi Greatrj ?ACIC(if Apiilickble), ._>g. < -. ... a..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. It.
❑Experimental Technology ❑Subsidence Control ft. ft. .
❑Geothermal(Closed Loop) OTracer `2ialtiDI 1sTG'I., :(atrac itdittolal•s"3teats=ifneceas8cv) }0? M . :_. v"
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) _ .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. ft.
4.Date Well(s)Completed: 3 1 ! Well DO 3 oft. f 0 ft. r" 81
rid?, MK'
ft. . ft.
5a.Well Location:
:�, �p-�}� i — -— -
Cl� i"f�tolQ/ i i$� ! l� ft. ft. _ s r _s ' _.
FacilitvlOwne-rName Facility ID#(if applicable) ft. ft. j A ^ [UC`t19.i0 '"Illif tr(,� 14;11 ft. ft. Or. ` -
Physical`�dress,City,and Zip i ( �ft ft, if s
�.,'Z�S.a�:�.Yl - x., -;x ..,c; J.,f�;s....r vomian o S'.N gmk
County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.
(if well field,one lat/long is sufficient) 22.Certific•tion:
N W '. 1 I i 3 LI
Signature.3 edified Weytfikl1).(61A
ontractor+ Date
6.Is(are)the well(s): Permanent or OTemporary I !
le
By signing this form,I hereby certify;ihat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Const uctton 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.
I
repair under#21 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:. 1 6 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 c@200'and 2(0100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
/�
10.Static water level below top of casing: • a v • (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+y
11.Borehole diameter (Q I1 1 -(in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
t-0.1
12.Well construction method: a I r rot 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produ I ing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) a® Method of test:
oviJ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: p l v 1 Amount:A 1' 1-6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018