GW1--06318_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: '
1.Well Contractor Information:
Tasion 1gt Ii , '
;�.,¢ , �gitzoga-��_a ., z mm_;N > ; may x a. m,u.
Well Contractor Name FROM TO ,DESCRIPTION
1, 1 q A ft. f OD ft. x i A o 1°1
NC Well Contractor Certification Number 15`<t7,
dg ���111 ey, '(wa ei W&I
l € Pump FROM TO DMETER THICKNESS MATRIA V( /�J it ft 1. to PVC
Company Name &w .. )14q€67- I6 GA70, ft.TCTS(i?„6theririalclosed=lltt6py , j,',�. 3.%'_„,u.w,F`�,..2.Well Construction Permit#: y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.VIC,County,State, variance,etc.) ft, ft. in.
3.Well Use(check well use): is it i in.
t'11 O,CREE't.,. ..,.:r....` ?awa4'frq,s _ .-'' _:�litt a",`.u.t 7`.. ,M "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL~❑Agricultural ❑ unicipal/Public ft, ft. in.
OGeothermal(Hearing/Cooling Supply) residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation • ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACPME METHOD&AMOUNT
Non-Water Supply Well: 0 ft. .b ft. L,�fitav'1. o A f i3J 1
❑Monitoring ❑Recovery ft. ft. �r 1 I 1 it.CJ►
Injection Well:
ft. ft. I;
❑Aquifer Recharge ❑Groundwater Remediation .
19 SAND]GRA'.4 L'.?i 0fa Fp1 chbleJ r,.r . ....p. ;.,. v..;,.,.' Ma::
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 610.kItriIilCri#ti(att`ach.$d7 doiial"sheetiViide'saai �5 ;... 'A��r t;,:' g .5':
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Re 6_ ❑Other(explain under#21 Remarks)
f+ Alft. ! ft. p 1,
-
4.Date Well(s)Completed: Well ID# 3 i9,'
ft. rG S
5a.Well Location: 3 0 ft. 0 ft. k(-o tub n r tie.k
S J®l: Val l'i1c 4 O.I to ft. I iSo fu c^ lip i rot .
Facility/Owner Name Facility ID#(if applicable) ft. ft
4 ' f�1 tk6t. Jr' 1W.N IQ. Fgre4. a l5 ft. ft. i hb..,..„..G.::., vPA. L...)
Physical Address,City,and Zip I 1�J�( ft ft. n r Z ;' (l,
gi kt, g110
'a`M !i• 3 ,-f1'.i;.RI�il Rx{iY..:i. .,cr��'.`tz:'� .3t,,.:.,:..P?�a+?.i'•.'t4_fa tllr,.'5--Sit'�,cold -?1. .:. ... ......
Co ty Parcel Identification No IN) lr'"' ": v�'I
(Pi,';ci;'_:';;-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W aa )A a r all
6.Is(are)the well(s): iPermanent or ❑Temporary
Si of Certified Well Contractor Da
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 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.
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 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
10.Static water level below top of casing: )%-0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+'/ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: `p f a (in.) 24b.For Injection Wells: Copy1 to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: VL tr I-0 ; ' r 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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
✓� p,n\ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ✓` Method of test: 1'
13b.Disinfection type: ktr th Amount: i)i 1 6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resouri es Revised 6-6.2018