GW1--06359_Well Construction - GW1_20241025

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WELL CONSTRUCTION RECORD(GW-1) For-Internal Use Only:
..Well Contractor Infor}maation:
GZrir or I
- /$44,1i4-)-- . , $
Well Contractor Name FROM TO DESCRIPTION
ft. ft I
,4,C1 A ft. ft. I I
NC W I Contractor Certification Numbert ,.
.� ',TSaOU;I�EIt�C�A�SY1�G*(fol'im�ld?otie�etiiw�llsjtQ$=IS)(1�It+(ifaP llcdhle)�;
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MATERIAL
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2.Well Construction.Permit#: 7 / O� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) . ft. ft. 1 In,
3.Well Use(check well use): - ft. ft. i • in.
MiSCR} Ivy _ ,, e .c i ?MOMI g y e: i:_.aa s It u, axf sai .M
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
17Agricultural ❑Municipal/Public ft. ft. i• in.
OGeothemial(Heating/Cooling Supply) 'Residential Water Supply(single) i, ft, I ',in,
❑Industrial/Commercial • ❑Residential Water Supply(shared)
❑Irrigation 0 Wells>100,000 GPD FROM TO MATERIAL. -�- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. „AO ft. [���-art} 1 e p t(bred t g. b. 5
❑Monitoring ❑Recovery; ft. ft. U
Injection Well:
ft. ft.
DAquifer Recharge 0 Groundwater Remediation
;r19:<SANDIGKOEL-PACK(If applltlable)st.... .. .. .
❑Aquifer Storage and Recovery , OSalinity Barrier FROM TO :MATERIAL EMPLACEMENT METHOD
❑Aquifer Test • N., ❑Stormwater Drainage • ft. , , ft.
❑Experimental Technology "• ', ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ' ` OTracer A0.SDRILIS1NO 7sOC(at"taoleailiitftpnaVilli ets;itjneceitsaYy0g •: .&:._
FROM .TO DESCRIPTION(color,hardness,sollrack type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks): t j
,l Z rt. 1�Lft. 1:rfi G l a-, SGLKd 6 yt e'
4.Date Well(s)Completed: /V�/b-.J}l Well ID# 14/.3't. .l/Q�ft. r.tn :
'T
. 5a,Well Location: ft. ft.
7I I I I ‘ f ft. ft. . �>;i%�: `'':'-�ie: :��..."n
aL D Y l Mr W 1/C ' ft. ft. 1 'Z z-,t._.,; da �,e,
Facility/Owner Name Facility ID#(if applicable)
4419 � - ft. OCT 2 2024
Physicall4ddress,City,and Z/ip ft. ft. .. ..- -- -..,t 4x}
�I�t✓-1 lf E21:;teElvlAitKs r al,,w 1 ' r, •
.V dV•Lrv../
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.Cer' cation: • +'
A-6-"9n664 N '— gl, (e(2o-v w }� , • iD l -�
6.Is(are)the Well(s):*Permanent or OTemporary Signature of Certified Well Contrac o Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well:. ❑Yes or .PJNo 154 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 of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fornt. 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well•depth below land surfacer (ft.) Submit this GW-1 within 30 dais of well completion per the following:
For multiple wells list all depths fdyferent(example-3(0200'and 2®1001
f
24a. For All Wells: Original form to Division of Water Resources (DWR),
/10.Static water level below top of casing: d .O (ft,) Information Processing Unit,117 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'(
24b.For Injection Wells:.Copy;to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �+� (iri.) Program,1636 MSC,Raleigh,f i 27699-1636
Gt 12.Well construction method: rO -Y) 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 produ cinig over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ii ' t Method of test: Cjj -i r - 1
13b.Disinfection type: c k J D Yin 6 Amount: D�-- ���s j
ti /
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018