GW1--06337_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Info ation:
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Well Contractor N e FROM TO DESCRIPTION
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ft ft.
NC Well Contractor Certific 'on Number
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ot ` 'Ili\ (� 1 (,. „i .fp6DFROM TO DIAMETER THItKi ESS MATERIAAL`
I'V 11 �J WV 1 1 , t ft. ft: .> 4. lit V v
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Company Name .J �r A6:VtEt E f t)1tnilAINa(gt'olbtetiii:WC16keT4uou a •� g_�K
2.Well Construction Permit#. FROM z0 DIAMETER THICIINFSS MATERIAL.
List all applicable well construction permits e.WC,Count,State,Variance,etc.) ft. ' ft. ! in.
3.Well Use(check well use): .yy��.t,+tssi�ft ft. , in.
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Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural C$4unicipal/Public ft. ft in. •
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 1t ft, In.l
❑lndustrial/Commercial ❑Residential Water Supply(shared) .:4 � �7 � : � � ,- 7�ao . 4 r4 i—S*''c:C ? -
4
❑Irrigation °Wells>100,000 GPO FROM TO EMPLACEMEN METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 10 ft' g7Efighikijr0tJ1 et
❑Monitoring ❑Recovery ft. ft. t tie
Injection Well: ft ft. 1'
❑Aquifer Recharge ❑Groundwater Remediation '',1 ;
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❑Aquifer Storage and Recovery ❑SalinityBarrr►er FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft. I
❑Geothermal(Closed Loop) ❑Tracer :0` ttll4 l tstfatl dditiauati1ieets`il n ceseai tif.: ::.,. fi ,::. � T a-.,;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCRIPTIO (color,hardness,soil/rock type,grain size,etc.)
�f J � ft. �� rt. 5��1 �/�� �i
4.Date Well(s)Completed: gti' e ! Well ID# a��ii ft 7_0 0 ft' 5 4 p is h V y-
Sa Well Lo ati n: 10V it. 30 0 it. /q ca h t Ft ro cR ,
ant,60.1 tfLoMdo
ft ft �/ � rt • _ 7)
Facility/Owner Name Facili ID#(if applicable)
.3 0 CoaGnAI�ti1.5 Tr q I ft. , ft. DC 1 2 'tU[4
PhyrsicaallnAd`d,ress,City,and Zip ft. ft - r r,V t s111
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22.Certification: a, 1
N W 7-2-5/ 15-- I L.-ZI)
6.Is(are)the well(s): l$�Permanent or ❑Temporary Sigma of Certified 'e�ontractor Date
�[A By signing this form,I hereby cart&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L�f1Vo 15,4 NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill out brown well construction Information and erplatn 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: If 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: f).0 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'
11.Borehole diameter: Via (in.)rtia 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
et( Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: N irY24c.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
l0,_„q_b_ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: . f
13b.Disinfection type: f I Amount: I ` 1`