GW1--06338_Well Construction - GW1_20241022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: } •
1.Well Contractor Info ation:
*3''ow TI4;x�;�'I:lsla s;;`.t a ,: ;, t, t t V✓��s'a tM.a,Tmik,,.>��r a
Well Contractor Name FROM To DESCRIPTION
ft. It.
NC Well Contractor Certification Number r_ _• .
2'XSaDI'1-2'Fr,•Ci1S]lYG(tot~inb�:�'ell:iitils�C3R�'1+X1YL12(t€,ap)Ece61e1 .,„.�;..�r,�.;,Y":
.I 1�') P bo k V v#,) FROM TO D ,IAM,T R THICKNESS MATERIAI,
Company Name
1 JJJ''CCLL�r vV d ft s' ft ii in.
^� °� / (r. :f SINdO1SIBSll�i tiattaiiiiMffiWt4iiiiiiI . W.I:i4c�._--• gt "'? :
2.Well Construction Permit#: C'r`er -Te t a 4 it) FROM TO DIAMETER! THICKNESS MATERIAL
List all applicable well construction permits(t. .UIC,County,State,Variance,etc) ft. ft. ! in.
3.Well Use(check well use): ft ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL�f.`�BSc.t ti11 r.Y,�'ir F;0 .i'`.a•':NLt 3 ,�`:1.�b.. ,i N.,2At�.3`w c'•�Y..;u etli,ti* v
,
❑Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) 6/Residential Water Supply(single) ft, ft In.
❑Industrial/Commercial OResidential Water•Supply(shared) , ,� ,,,�y„ - .�,�
l$:GIi;Q�f1'1'y,�v3';,tt� ,.: �,..�.�...r_,.z:�:cV;W5V:?.:., AVa,.:e..43-f�!AM.xi.'L!
❑Irrigation ❑Wells>100,000 GPD FROM TO _MATERIAL EMPLACE OD&AMOUNT
Non-Water Supply Well: 0 ft. 10 ft. � h-t e 4 eaut� l•t P-
❑Monitoring ORecoveiy ft. ft. 4 F1 l(
Injection Well: f
ft. ft.
❑Aquifer Recharge ❑Groundwater RemediationaftiSAD 'IZ P `eMtilppuchti[eFIMMI Pui . ,g„x�
, .:, ag
ClAquifer Storage and Recovery ❑Salmit Barrier FROM TO MATERIAL EMPLACEMENT
❑Aquifer Test ❑StormwaterDrainage ft ft. j
°Experimental Technology ❑Subsidence Control ft. ft. I'
❑Geothermal(Closed Loop) ❑Tracer ,1o'%Y;RTI?I Iltf<;li'tiO.atiiaelC')ldditiunldshcets_itiiassgiii Ra,,.st t.,R ,��r ,
OGeothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardne solYrock type,pain size,etc) ..y
0 it. ft. t✓V G-, 4 ,jai'i
4.Date Well(s)Completed: 9- ✓!a11 Well ID# P-I ft 39tt_0 ft. q It ini......c,
t
5a.Well Location. B• ft l/
Kt �d_�,p (o( it. ft. c. 'C e a' u 6 'rr �: !)
Facility/Owner Na Facility (if applicable) it. ft.
me
Lt N c.� rn ft. ft. NT 2 2 2024
Physical Address,Cily,and Zip ft. ft. i ri`i r 1,,Vl
PAK 14-I t 11 050 Lia ,imattivialioceoimiw,::.0140zzioizo,to,,titeswizv.wai,...vg,v44§..;-,.1
1
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.C 'fieation:
N W 1a5 -21
6.Is(are)the well(s): i fiermanent or ❑Temporary Sign of Certifce 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 15A NCAC 02C.0100 or 15A 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 ofthis record has been provided to the well ownerr,
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: 60 24.SUBMITTAL INSTRUCTIONS•
9.Total well depth below land surface: (ft.)
For multiple wells list all depths fd different(example-3® 00'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Stade water level below top of casing: �® (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casino use"+"� PP}1 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Gt !ld (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ar t%(T 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: V t�' f 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
47�i" Pernut Program,1611 MSC,Raleigh',NC 27699-1611
I
13a.Yield(gpm) Method of test: p/\, Q
13b.Disinfection type: � h' Amount: r./ [�
Form GW-1 Nnnft re,r. a n-�