GW1--06320_Well Construction - GW1_20241022

WELL CONSTRUCTIONRECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: , _ ty +,in y c1 , ,
1/ V 1 Po �,�S 44,`.F17''t'.1' ....d.•..''7v,,,,,,r`.'`�'}'�;.".4,�e'g,,,ti.. , �'; n.t;.�-�s ,,,,;ai'3:,„:,„,,,,,,i,.�'., t `�.:
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• FROM TO DESCRIPTION
Well Contractor Name fa 170 n I Q�?
-fi r ' 36D ft j 2.51 ar m
NC Well Contractor Certific tion Number c �15
.r~.rr-zs �tturerr'1F•3'nfin'iR. ,�ok h'd:rfa�sLA RP 5a" Atati`t. a l., . -`4
�i� !� ( r� ��/1 cp, FROM TO D1A, EVER THICKNESS MA• TERIAL ," it
l-�t� 'l �oa e, �i�1 1 ��l�r `� 0 R. `$ ft.
( 1,'S..in. s 1 '1315 4r1411/46i4Zeo
>romparry3datn4 1 '1 iC:Ii�fi FACC:#`5i1 i4R' B#S�igtithdibet<mulifii ed-To.6ii1+'is 'A"iReW "".,
2.Well Construction Permit#:j V 111.s pt FROM TO DIAMETER THICKNESS MATERIAL
° - at)List all applicable well construction permits(i.e.UIC,County,State,Var f4 e,etc.) ft, ft. in.
ft. ft in.
3.Well Use(check well use): . , �. P `:a sr=1?'
v : .r23 x v. Ll W ,.
4�/�.l�`�'RX'+�'i'�si'„:4�'k'+'r;4.;.itt;..��' ih��;F�,n •4.• '.�.� c;' �'I�N1J _.�#r`tv s3;,1,::..:...t�•.
ii Water_:Supply Well: 'Wee' TO DRelsiai TrR S OTSI% TIiicKrr'Ess MATERIAL
°Agricultural ❑ unicipal/Pdblic - fr.J ft. in..
❑Geothermal(Heating/Cooling Supply) EVResidential Water Supply(single) f, I ft. I hii.l.
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O lndustrialiCommercial ❑Residential Water Supply(shared) 4ff i;Q'Uf 4V,;<. yj, .. ,r fin• , e.r.�s .01 ,=F t <<.t•.'`'
o Irrigation [?Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ® ft. 1.6:, ft. i 1i-o h l te i(
❑Monitoring
°Recovery ft. ft. I Ott 1 1' .19
Injection Well: ft. ft
°Aquifer Recharge °Groundwater Remediation i $ANi1t VtiiYAtK4(ttapt able k- L, 1• ,-
=:
❑Aquifer Storage and Recovery °Salinity Barrier I FRoM l TO 1 MATERIAL. -__.__ I EMPLACErMENTMETHOD
❑Storniwater Drainage R• -f.
°Aquifer Test
°Subsidence Control ft.
tal Technologyn � :....,.
• XP .:.
❑Geothermal(Closed Loop) °Tracer .i lit l`f; L'11uO'lib ti :dildiiitiiiiiii ehte"tsif-itoc"siinti,7=t ;:r":: r }' r `•;.
FROM TO DESCRIPTION(color,hardness,son/rock type,grain slze,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) g,
4.Date Well(s)Completed: 31 21 I J4 Well ID# 50 ft. E s o ft- 5 cliri d.s+o(^
ici
Sa.WeII'Location: f�t�: �1�
TLE. 1 Imes
ft. ft. e v'c,.- ''
Facility/Owner Name Facility ID#(if applicable) "�ft':' '�' ''--1
t
ft
Physical Address,City,and
[, .i ..J
County Parcel Identification No.(PIN)
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56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
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(ifwell field,one lat/long is sufficient) 22.-Certification: !�I
' ta* .-ii k -31D`'-'1)."244
6.Is(are)the well(s): Impermanent or ❑Temporary
Signature• ertified Well Contractor Date
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 1.5.4 NCAC 02C.0100 or 1SA 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 ding"raiii or additional well details:
You may use the back of this page to provide additional well construction info
•6.1 u, c ion,only I;i o. ""°"-L""r icate TOTAL
, :::....,6 v (add'See Over'in Remarks Box)'.You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S 0 o (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a)200'and 2®100)
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
Ifwater water•level is above casing,use"+"
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(_1 l/Lfi P.) a 24b.For Infection wells:Copy to DWR,Underground Injection Control(VAX)11.Boreholediameter: 1� program.'_IE4fiMCf:.Releioh Nr.7.7649.1 c t
12.Well construction method: CLl r rofa try 24c.For Water Supply and OI el-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 produling over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 4 Method of test: 0 0 liii
Permit Program,1611 MSC,Raleigh,NC 27699-1611
''ss
13b.Disinfection type: Yrl+1ft Amount:_AS. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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