GW1--06526_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
c)10(n We o f_
x�LwATzvEs
FROM TO DESCRIPTION
, Well Contractor Name ft. ( c ft, i y�g
2.41g 6 5 ft 325 ft. j5-0-1
01 " ,
NC Well Contractor C��e�yrtyification�Nu�7tnber y� f� }��p� q { y��y�j 15:011TER CASING for i nitt 41 er fells 01CLINRR(if ap likable),.
&mane.1T 4 . !.. Y* tX. t J .LJL 4- R.i [' p/to i t v tt.:.•• I ft. T� tft. t y(y DIAMETERiin) THICKNESS MATEC 9i�°AL
Company Name ��((` }/��`{ r� f � 16;3fiTNE8 CASINGbItI IIIIIII rG,Ikeetherinaleleted loop)
2.Well Construction Permit#: )S.S LO 4-�/`j OZ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County.State,Variance,etc) ft. ft. I in.
3.Well Use(check well use):
ft. ft. 1, in.
Water Supply Well: :11 SCREEN
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft m
Industrial/Commercial Residential Water Supply(shared) 18::GAQII>
Inygation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. I ft. � ,�(e �;n,��p „ i p ,(�_
Monitoring Recovery ft. T ft. `4 I ►t�r-''4'�lqLi✓ li►./:�^-
Injection Well: ft. �'�
J I
Aquifer Recharge Groundwater Remediation 19•S►ND/GRAVEL PACK(if applicable) NO
(l l CT ,
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EWaLACFbtF.NT METHOD
Aquifer TestStorinwater Drainage ft. ft. 1. rr' r'^,,; --r �.R
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 0 DR1LLINGA LOatatficlit ddrtiana ibidittf necessary):
FD D TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return)
ey i Other(explain under#21 Remarks) (/�P n TO ft.
4.Date Well(s)Completed:61) / `4 Well ID# 7l i3 ft. � f 5 fr. ?rail
iOdl1� ft. ft.
Sa.Well Location:
fCC ft. ft. r
.a IW tesf ft. ft.
Facility/OwnerOtrklilat fame it N Yf Facility ID#(if*applicable)C
1301 6(Alit' r6rAs - t;i t ts /ver g 1 J ft. ft. •
,
hysical Address,dity,and Zip ft ft
' de kainREMARKS /��
County Parcel Identification No.(PIN) 8- P`l Y 91114)4141.A 1 � /11 19-' tea/onto/4' _,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
C�75 S N C I w bai 1 0
6.Is(are)the well(s)*Permanent or 0Temporary Signature of Certified Well Contractor Dat
.By signing this fonn,I hereby certify that the well(r)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or RiNo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constnrction it formation and explain the nature of the copy oft/tis record has been provided to the ivell owner.
repair under 421 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 site details or well
construction,only 1 VW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: .
SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: 345 a (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i([dier•ent(example-3@,200'and 2Q100') construction to the following:
10.Static water level below top of casing: I 00 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use
"+"f� - 1617 Mail Service Center,Raleigh,NC 27699-1617
nti
11.Borehole diameter: ,✓ rat (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: L U construction to the following: i'
(i.e.auger,rotary,cable,direct push,etc.) LI
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
p � r t
13a.Yield(gpm) 15 Method of test': ,R-4I1J 24c.For Water Supply&Injection Wells: In addition to sending the form to
jj the address(es) above; also submit!one copy of this form within 30 days of
13b.Disinfection type: itn4 Amorin i 18 completion of well construction to}the county health department of the county
where constructed.
Form GW-1 North Carolina DepSrtntent:'of Etnvironmental Quality-Division of Water Resources 1 Revised 2-22-2010