GW1-2021-00848_Well Construction - GW1_20210322

I KUILA-ION RECORD GW-1 For IniLKttal Usc Only. /I�
I.Wdl Co ch' lnf°f"tion: f/1
L' IA WATER ZONES
Well CAaleactor Name ,Q rIIOM TO _
n.
NC Well Co vsclar, CeniGration Number S.OIfiER SING for and-coM"Wha OR LINRR 7E2lIAL
.� ::-.L :,/. sTtoM To mAMaTta Tr°ctotEss
4 . _ ` } . n rt Jjh. 111.
Company Name
1C NNERC ING OR 7VBD4G aermat MATFAtAt•
2.Well Constroetion Permit q: EROM To mAMeru TO CKNESS
L.,all applicable»rat corm tan pennies is U/C.Co.,).Smtr,Vinanrr.et') It. fl. is
is
3.Well Use(check well use): ft fL
Water Su 17.SCREEN MA'fi°1')t•
PPIY Well: fallout TO imijuCf►1 st.OTSlit Ttli[KN6S
Agricultural ❑ KipaVPublic �'R. �5%R 9 In. g-/7 e/`
Gcdhcm lal(Rcaiting/Cooling Supply) Radcwtial Water Supply(single) 7d 6
lndustml/Commmial []Residential Water Supply(shaned) LLGgOUI' O°NT
Irtieation root TO atAT►dttAL wth.LcoAnrr vrfr D AM
Noo-Water Supply Well: fl' S rt 41
Monitoring Recovery rt It.
Injection Web: n, fl.
Aquifer Recharge ❑Groundwater Repudiation I9.SAND/GRAVEL PACK if• It.aaak)
Aquifer Storage and Recovery ❑Salinity Barrier tROM To MATrAwL rA411 A10 % trO°
Aquifer Test ❑Stormanita Drainage "�fl• )�—fl' ` - Nr /7c'✓'�•
Expennicotal Technology ❑Subsidence Control n. It.
Gcothemui(Closed loop) []Tracer 211,DRILLING LOG IMneh odtlWaat abee tr e )
�
n 'a rite. t
Gootlt<rrnal(llp[ing/Caoling Return) ON FROM TO DE ffir Iron[afar,MNw+v will
(explain order r2l Remarks) n. fl. �, J:•`
fr• fl- /
4.Date Weil(s)Completed: I Well IDM Sn
R : fl. ( G
5a.Well Location.
fL
rt_
Facility/Owner Name Facility[DO(irappinable) ) ) �.
Lim
Physwpl Address.City,and ZT
IY I AL 21.REMARKS
Parcel ldcai(ua[bn No.(PUN)
Caunry . . '
5b.Latitude and longitude is degrees/minutealxcoods or decimal degrees:
(if-well field.am hobng is sufficient) 22.Certification:W /
;�� 5
Signature of Certified Well Conaacror Dale
6.Islar<)Ihe well(s) rmsoeo[ or ❑Temporary
By signing Celoan,1 herrhr rrrh'Iron the xr/l/J erns(»rrel eamovrtd in accordance
AC 01C.0100 Well Construition Standards and lhar a
well: Yes or ❑No »ith ISA NCAC OIC.0100 or 13A NC
AC
Is this a repair to a°existing ❑ arpr of nia,record hat been pruvidd to the»cell over.
/Jthis u o repair, ea ab,,ec u well at,the balinn iba,mriun and explain the nature o/Ihr
repay talder r11 re�mr6 section or on the back o/tAi�Jarm_ 23.Site diagram or additional well detalls:
You may use the back of this page to provide additional well site details or well
c For Geopron y I G or is needed. In Geothermal TOT Wells having the same construction details. You my also attach additional pages if necessary.
eanstruetion,only I GW-I u needed. Indicate TOTAL NUMBER o(wells
drilled: SUBMITTAL INSTRUCTIONS
9.Tool web depth below land surface:
(ft.) 24s. For All Went: Submit this form within 30 days of completion of well
!'err multiple»ells rut all drpNr iJdigoent(rsamp/e-3(a1100'and 1(aJlOD1 construction to the following:
to.Static water level below top of osillg: / l (ft.) Division of Water Resources,lnformntbn Processing Unit,
//»user/e,rl u above rating.rue"+" 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lC' (i°) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit arse copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
fir.auger.mainly.cable,duct[pup esc.l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent",Raleigh,NC 27699-1636
Method of leg: 12 the For Water Suppabove,
is Isubmit Wells: In addition to sending the farm to
13s.Yield(gPm) co aletion of above, also submit he copy oe this Dam within 30 days of
county
�-: 7/l.-',s;, Amou°t: `S' C".- completion of well construction m the county health department of the county
l3b.Disinfection type: where cOmllueted.
FmnGW-I
Nonb Carolina Department of Environmental Quality-Division of Water Resources Rev tied 2 22-2III h