GW1--06310_Well Construction - GW1_20241022

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WELL CONSTRUCTION RECORD(GW.11 For Internal Use Only:
1.Well Contractor Information: - <.
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PROM TO DESCRIPTION
Weil ContractorName fr. am& �® , ,d•
Cl
lal 9 fr. ft. Li t
NC Well Contractor Certification N mber tl.'i`l t .,• :.:Vag '(I 'll "�"�•C
Ai pb a virl ' k:1,1 i C.p FROM , TO »motTrot MATERIAL .
Corapuy ame ' i f ft. S It. ��. lit. Ve
. '-WL,f41.41,0,egaPV
2.Well Construction Permit#: (' IN Cl,,5 J . .0 :( , PRO, " TO DIAMETER A THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC.totarty,&ate,l'arl etc) ft. ft, li to.
3.Well use(check well use): , ft ft. r In.
VVaterSupply Well: OW n geINO"+ rank;'' .;,* ' t :'' SON
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgriaultoral Cl unlcipellPublic ft. ft. a In.''
°Geothermal(Heating/Cooling Supply) LVRexidential Water Supply(single) ft. fr. in. '
ClndastriaiCommercial °Residential Water Supply(shared) ; 4 M,., "'`ti .;, T ',� a, 1 ;
Clririgation °Wells>100,000 GPD PROM TO MATERIAL EMPLA METHOD at AMOUNT
Non-Water Supply Well: m It ib R• v 1U it
°Monitoring DRecoveiy it fa 1 A
Injection Well: 'Pi( P
ft. ft. II 1
ClAquifer Recharge C7GroundwaterRemediation A -0 riM itp at
OAgnifer Storage and Recovery C(Salinity Barrier FROM TO - MATERIAL ' EMPLACEMENTME HOD
CMOs Test C7StonnwaterDrainage it. ft. ii i
DExperlmentai Technology °Subsidence Control it It. 1'
°Geothermal(Closed Loop) (]Tracer '€ ' + tF a Ill Si ►Ye ' ,W `,tti ''• i.
OGeothenmal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM ! DPSCRLPTIOx(carer,_hardness,aoa/tx+ek tyoi,sere,tRe,Met •
0 ft. 10ft.
4
4.Date Well(s)Completed:41"al)" 1; Wen 1D# 30 ' too " .$dy y,f he',
Sa.Well Location: `o 0 ft0. v^i 6 b iL q rail iT'� ro 1
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1 urn
1 t Cia vv,5on .. .
Fat . Miiir4
/oWeer aw I'eeliiryiCft(If app6aei)Ie) ft. 11.
r ft. t<. 6f T 2 d 2024
PhysicalAddress,City,andZip iL ft. u,:�: r:. -..1 �'-7...w.`. ,.5�:
VIG�\S, (15 O3 5 5 i f 1 g' Y. �iR'w�:-c`_.:„. : ?2GS. d,3r. .: �7:�, ;'` ;.:;
County Parcel Identification No.(PIN)iS
5b.Latitude and tongltude n degrees/minutes/seconds or decimal degrees:
(if well field,one tatMng is sufficient) 22.Certification:
N W
1(111'24
6.Is(are)the well(s): CILPermanent or °Temporary 5 of Certified e i Contractor
/� Bysigningihlsfbrm,Thereby car*Mai ihewell(s)was(were)constructed in accordance with
7 i Is this a repair to an existing well: l7Yes or fKo 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Weil Coasdvction Standards and that a copy
If this is a roods,fill out known well construction in)bnnation and explain the nature glitre ofihie record he been provided to the well owner.
repad•under 4021 remarks section or on the back Veda
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 ifnecessary.
drilled: ( 24.SUBMITTAL INSTRUCTIONS;
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9.Total well depth below land surface: 1 r (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdifferent(example-3t).Y00'and 2®100'}
10.Stade water level below top of casing: 0-0 (ft.) 24a. For Al Wells: Original form to Division of Water Resources (DWR),
afrvater level is above eosin."
itse"+" � Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (Q l(11. (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a(r mart 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger.mtaty.cable,dtrectpush,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
',• 13a.Yield(gpm) Method of test: 61PUJ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: ►4T v, Amount:IL I l �. •