GW1--06324_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
2.Well Contractor Wormation:
.1(J5L/ 1 1 y E 1•�ES,M,;�ca. s, ip. iA .D.a-f`",,ate„'. #„S l '�, ,r•;Y�= yti
t.Tw� �5 `, '� 4TG7. ?t. i�41•xt�:xaa'�.U,. ��:t...'Y.:'A? .f:�'i' ,1 .t .t •�:i•.
FROM TO DESCRIPTION
Well Contractor Name ft. P ' .- --i 1 A .. /O 0 ft .i1 5i
NC Well Contractor Certific tionNumber Y�yq �(?ASM,E`r(Coti3iiiiltl atted'iit811s)i73It': NEIIl f-abp`Iicalil g.��t `n 'r#
?� FROM TO rat THiCIuyESS RL��(q 60he UJ'�1k C �u II C. ft �.ft. � in [ ri;rz �,,�„ '
Company Name P7G:�tlR; I1V dgentriechl"s tiose&:laop)>} k..x`.i `.t l•.} ".1:'
7 1_� ,�G« R.�tkSl
2.Well Construction Permit#:� 1W - I 0 I liq - a 0 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.(JIC.County.State.Variance,etc.)
ft. ft. in.
g, ft tn.
3.Well Use(check well use):
Yk'!Aciorit,:-:. %rr,-.,,,: .,.?�s rr,k"'Cf''-i',�':.-4<- "'i->s.'xt .`r z;'.,`-"r-,:".'.�,'-i,7•,'..-. '�:„t"
I Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
11❑Agricultural D unicipal/Public , l ft. I
ft. in.
ry ❑Geothermal(Heating/Cooling Supply) ItResidential Water Supply(single) ft i ft. in:
DlndustriallCommercial ❑Residential Water Supply(shared) :, :GRU'.iITs ';f M mr' s w;,1}, f,;,;, ,v4.,X ,k,_ *01.01.KK x
❑irrigation ❑Wells>100,000 GPD FROM TO MATE',• EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. -O ft. ''4,, - -
a
❑Monitoring • ❑Recovery ft. ft. a 'ln 1 , "ri)(cc/
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation ,LSl ,Xtfie), 1- ; '04wi `aiV:'(Z7 t xw "i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ( TO I MATERIAL I EMPLACEME�ii TMETHOD
❑Aquifer Test OStormwater Drainage n' ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
•
❑Geothermal(Closed Loop) - ❑Tracer '0;`,'>1 lid. liF7 '#di4atfl"iddli)aaiit2a'lieet ifilites3ui•y)'' p `�:'iM.4M"ter` " .
FROM TO DESCRIPTION(color,hardness,soWreek type,grain size,etc.)
❑Geothermal(Heating/Cooling etum) ❑Other(explain under#21 Remarks) �y ft it 5 �� b�
4.Date Well(s)Completed:aD.1 J 2d! Well well". 0 ft. I n it �f rit/1 p t 0 C
I ft ft. ✓ 1 m
5a.Well Location:
is
C t7 Fe rlt(Tl1 V/y it ft. V i '3_v y
Facility/Owner Name Facility ID#(if applicable) ft. ft. 0 C T
3(e' 10 CI ft) P ih81 VG e. Vtif e4 'Xi S i it ft. •
�.... :: .
•
Physi �ly�Addres©©s,City,and Zip I 7 q) �ql//��yt� ft s
^'��L/ 7�� 1 / 0 V V f art ycims ii .4s+ S''.'Corti;si;,."ta.'',,. 4 k 4•;,,11. ro:;? '}w .-„Lr''-iris i•i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweltfield,ono tao'ioug is suificieuej 22.Certification: '
•
N W i , f6A, #3f. ,...d6) A a_ a
6.Is(are)the well(s): (Permanent or ❑ Sins r/ of Certified Well Contractor D e
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 1i1 To 1SA NCAC 02C.0100 or ISA NCAC 02C1:0200 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 welil owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well jdetails: f
o v=r•......-,.u,m"r,...�,,..,,.a_r,,.....-,,,+w.,,...,..,.v..n,.,,,.;,,,,r 1--- You may use the back of this page to provide additional well construction info
- _only __ _.__e .._ _._ .._TOTAL
_. BE o �wells (add'See Over'in Remarks Box).Yon may also'attach additional pages if necessary.
construction, I GW-1 is needed. Indicate TOTAL NUMBER of
drilled: i 0 24.SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: I (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and AVOW)
10.Static water level below top of casing: at) ,it")
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: ! �1. (in.) 24b.For Infection Wells:Copy to;DWR,Underground Injection Control(IUC)
ClPrncsram,1636 MSC;Raleieh,,NC 2 i 699-1636
12.Well construction method: 0 tr. 0 fart ' 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
7� r >� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1" Method of test: 6 f
13b.Disinfection type: l(l- Amount: i(21'.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources 'Revised 6-6.2018