GW1--06314_Well Construction - GW1_20241022

I
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: .
1.Well Contractor Inform tion: ,
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Well Contractor Name` FROM . • TQ� ft. DESCRIPTION
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NC Well Contractor Catdfication umber y r I t �^
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i �k�:OT;k`l'•� `Cfi�1�Q(foitiin�t�a�'F�i�ve1113"f `F�IEB;(Ir�a'11�a51€)w����;t�:�;>t,��.,.
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/ QFROM TO ,TBICKWPSS MA ft. 6 1t1:27
in. i gfg 01 tlAi-L- rCompany Name qi �' ':1 6s tV, :-.. i3R6o osecl+iiiii1; �;f {'4'301.:
2.Well Construction Permit#:6 U r 3 1'4 3"' ''10 FROM TO DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(i.e,VIC,Count,State,Varl i"t.a.etc) n• K' in.
3.Well Use(check well use): ft' if' 't to
y�� ••��p�ypy�{ ,,�Nr.;it4:y.;iy§li M-1:7'c4 �A n:-'b`+�t- =•i!'t'�'- r"N;IK •..µEau;,r'*'.n�d±��ki
Water Supply Well: d ��4HiK9+y f4 diV 4;�-:1;. :wS 1LPekT u�vt: CC•$.1•�4tF Q ¢n1 s w U., �R'F.i YN X4; 1i
FROM TO DIAMETER I. SLOT SIZE THICKNESS MATERIAL
❑Agricultural 0 . •'c1pal/Public ft. ft. ia. •
OGeothermal(Heating/Cooling Supply) ►"esidential Water Supply(single) R. it. In.
Olndustrial/Commercial ❑Residential Water Supply(shared) x ti ;< y tr,;�',.�s�k>•��r t• a;,:.•,�`t' :•^, �•.
.-�� �l�'•`:��'%!<f»•a 7'>>•f_:l�vT}j�• �t.-•s-{..:v'S r�;.r.�,.'?•c��¢:;rr`�•���iava�;,
[Irrigation ❑Wells>100,000 GPD FROM rTO +MA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 9 fr. L:t0 R' beef Il eI of rc r
❑Monitoring [Recovery ft. ft. CifPack'
'
Injection Well: ft, ft. "i.
OAqui€er Recharge ❑Groundwater Remediation �,µ r
'sf9-9 ?a31* it lit filing ?'-�,+:::'�'s�'r 3��. t n,~:-::;;c4w.:.;Yi ;;::,
[Aquifer Storage and Recovery ❑Salinity Barrier ii1 D ' kCi pM TAR '�.. -� .. A, -{�;MET I;'FROM � TO MATERIAL EM]!LACEMENTMETHOD
ClAquifer Test OStotmwaterDrainage ft. ft.
[Experimental Technology ❑Subsidence Control ft. ft.
OGeothennal(Closed Loop) ❑Tracer 0.tiB xt=stghttat oft' ifrli,NiivaY fstif•' : . ii7, +,ri"a11 " t: Mr•
['Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) PROM TO DESCRn'TIQx(color,hardness,soil/reek type,amp size,etc
r �Q b It. 5 n' ,-.{dICX-
4.Date Well(s)Completed:i-I I "3 Well ID# „5' n' SO f' CI COI r'c i1
t
Sa.We Location: ..C.O ft. /04 ft. S I al A te f O C-I<
7 fro nef ll'�'f ft. tt. _..
F . /Owner Name Facility ID#(if ppliceble) ft. ft. :.y ,..,.s'.N :, ... .
21 j' 1 1 (�•l .4 i ' 4 i a )160 .' . U L T 2 2 2074
'calAdppdress,City,andZip fft.
/6084
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PhysiIf-4 I_ ;" t1%'. maxsg ,3 Yi=•tr2.'u. h,:4 a?wir3?S'vg'.z_.,?1,:`Y�it��.'!!ti.i., '' !,g',x.ol` i:-,
County Parcel Identification No.(PIN) u
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iatflong is sufficient) 22.Certification: / 1
N W /3 ;. r f' a �IA r©" -
6.Is(are)the well(s): Permanent or ❑Temporary Si ofCertified Well Contractor Date
By signing thisform,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Yes or Cho ISA NCAC 02C.0100 or 154 NCAC 02C:0200 Well Construction Standards and that a copy
If this is a repair,fill out known wellconstruction information and explain the nature of the of this record has been provided to the w ell owner.
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: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below if d surface: (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depthss ifdii ferent(example-3(a)200'and 4100)
I� t�ly 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: i' 0 (f h) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+'f�ii .�
11.Borehole diameter: (lrt. 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Programit 7 , MSC,Raleigh,NC 27699-1636
12.Well construction method: 4 C r fo, • 24c.For Water Supply and Ope`-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 producing over 100,800 GPD:Copy to DWR,CCPCUA
'bid
P Permit Program,1611 MSC,Raleigh,NC 27699-1611
.
13a.Yield(gpm) Method of test: 1'
13b.Disinfection type: .. " 1 1 wl Amount: i-- l lel, !
M... 1../....1.r'. 1:«.71......nc.....41:1•11.I.nnmanMl flnolity-Tiivicinn of Water Resavree9 Revised 6.6-2018