GW1-2021-01087_Well Construction - GW1_20210210

Jan, 29. 2018 10:58AM Env. Health (�/'�% /'� '— No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.W 1 Contfacro I11 ormAdo
Well ContrxtotName PROM TO DGSCRIPTION --- ---
fr (i.
NC ell Coaaac or Cea fication Number r'`l3.QUTER C+tS4�lI3'(6irinidtf<6f'-wells:OIt f ii IitaMb .�r o •.
FROM I TO DIAMUER THICICNESS ERIAL
� lt.
ft. C) ft. in. U
Co e
�Q /3 /% :�6:INNER.CASIiIGFUR',. tMG! Iherrual:iIoied l u. +
2.Well Construction permit 9:� v O�� ROM to 0 AMMA THIC►NM MATERUL
/.lunll applicableWdlemutn,e6onpemdK it..UIC, awry,State,Yariance,arc.) h. fr. in.
3.WelI Use(check well use): n. n, t"•
Water Supply Well!
MOM I To I DIMMER SL(Yr TnICKNESS I MATERIAL
_Agricultural QM 0
pal/Pablic R. it.
Geothermal(Henting/Crloling Supply) idential water supply(single) n (L
InduatrieUCommereial E31tesideatial Water Supply(shored)
:=76:QllOUT.:_._. w�:-,s•,_..�.�-o::"�.`<: �:E_'s"o_�_�:._-- ,•.ti`..�:
Irrigation Oat to MATE AL" MVILACEMEMMEMOD&AMOUTfr
NOR-Water Supply Wall: n. - rs. yN
Monitoring ❑Recovery R. ft.
7njectlon ell:
AquiterRecberge [)GmundwaterRemediation
�.
Aquifer Storage and Recovery aSalinityBarrier FR03I TO MATERIAL LACRMWMMMD' _
_. AquifcrTat 119tormWfiterDrainage n tt.
134erimental Technology Subsidence Control n n•
Geothermal(Closed Loop),.. DTraeer I:OG reifoc}i addlttoluiqlii:ets.ItiieiiaYii 61
_ Geothermal('Henting/Co4liri Rerun) 1Other ex lain under#21 Remarks PROM TO IMSCRIPHON color,bxrdftts%joiltrackMM VaIn srtt arc.
4.Date Well(s)Completed: Well Ina
5a.Well Location Re 30,
R.
ility/I><vnerName FacilityIng(ifopplicable) 2 «.
Physical Addmss,City,anti Zip n• �
County el Idesificarion No.(PIN)
5b.Latitude and longitude in dtgreeshnioutes/secouds or decimal degrees:
(itwau field.J to gin:affiaieat> �/ ��� /� �� 22 Certification: p��j �f 9-
6.h(are)The well(s)loPermenent or QTemporary signstureoceertifiedWellContractor Date
By signing this form:1 hereby cer*chat the wells)uw(e em)eorumicted,ti accordance
7.Is this a repair to an existing well: OYes or wbh 1S4 NCAC 02C.0100 or 19A NCAC 02C.0200 Well Coarrnteaon Standords and that a
((thins o repah,f ll Ord Jbrown Wdt eontrruuloh rnJarmaarion�nxiillffffar ant"Al eTti(i rna gJ ffta=�--001'0'of rhfr neeundhar been proilded ro she ivell owner,
repair under e21remanit section oron the back ofrhisfann'
23.Site diagram or additional will details:
8.For Geoprohe/DPT or Closed-Loop Geothermal W! i the same q You may use the back of this page to provide additional well site details or Weil
construction,only I OW-1 is needed. Indicate TOTA4 id f OC construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,=' ^(ft.�' 24n: For All Wells: Submit this form within 30 days of completion of well
For midnple week list all depths ifd fJben((erotnple. @2W'w&n@100•) 14)i I construction to the following:
10.Slade water levcl below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ffwarer level trabeveerr*e are"+" 1617 Mail Service Ccnter,Raleigh,NC 27699-1617
U.Borehole diameter.-'�(tn.) 24L For Injection Wells: In addition to scndntg the form to the address in 24a
above,also submit one copy of this lbim within 30 days of completion of well
12.Well construction method: U r►"Kt(
(i.a augv,rosary,cable.fiarct pasA eta.) �/ construction to titer following:
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
c
13a.Yield(gpin) Method of test: �� 24.For Water Supply&Injection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this farm within 30 days of
13b.Disinfection type: Amount: C completion of well construction to the county health department of the comity
where constructed.
FormGW-1 North CamlmnDepar mew ofEavimomeaml Quality-Divisianof Water Rcmurces Ltevisod2-22-2016'
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