GW1-2021-03912_Well Construction - GW1_20210823

r
4 For Internal Use Only:
i
MLL CONSTRUCTION RECORD It -1l
I.Well rttractor Information:
1. �J O To ESCRIPTION�
�r y���'�
Well tractor Name b FL g0 ft.� C ) s,.
o?qq?- A ft. It. M
N Well Contractor Certification Nu
t�Ct�r� y ti LAME f E ICKNF�S� i, TERIAL
mpany Name 4F It ft C09Z., In
L Well Consinrctlon Permits a20-24 0000 2408
U31 Q#approeara wrr ONdUua,remeltr(a CUM setae,ve lenca.eat) pd .PIAMETERESS :TERIAL .
111 In
3. Well Use(check well use}: ft ' In
Water Supply Well:13 _ :: j:t4.eta'_ c� i,=r y r_. ::�_ <viz'•,=•w-:;;ct:;br `�,
Agricultural 13 mwdpwftyk OM r • IAMETERISLOT SIZE~•THICKNESS TERIAL
13 Geoihemral(Healingcoang Supply) U Reddentlai Water Supply(Single) In
fndusirtaVoommeroMi I]Residential water supply(shared)3 Irrigation
OM rffrO RlAl LAGMENT MEfF1 &AMOUNT
No»Water supply Wail:
❑Monitoring 0 Recovery ftl it
Injection .
❑AquiforRecharge 13 GroundwaterRemedlatbn R MATERIAL P AGE
❑AQuita Slorage and Recovery ❑SaMity Banter ftl It
AoterTed ❑stormwowurainage
❑6tperbnental Technology 13 subsidence Control r F
❑Geothamw(Closed Loop) ❑Tracer RTO PTION(color,hardness,sdVm*type.grain,size,etc.
❑Gediemml(Heating Xowbv Return)O Oliver(explain under#21 remarks) ft
4.Date Well Completed: 'I�Well ID# it
5a.Well location: it- ft
FFy/Owner e Q G l( Facility ID#(if applicable) ft ft
1-3- /' C'&r ^e s Rat It
Physical Address,City and 23p ;_xa�_>>,X :, i :.X.MEMO
y..
County T— Parcel Identification#(PIN)
5b.Latitude and Longitude in degread)minuteelsecondsor decimal 22.CE FICA71ON: _
degrees:
N W Sign of Cartifled Well Co ctor Data
eyalpnlrN Oft AvmItaroy care ffidRwwa►(s)*rns(wma)o dhaccardemea&15AMW
6. Is(am)Rio well(s): 011irmanent or 13 Temporary 020•0100or15ANCACO2C.02oo►NYDftnft wSbftW serdaWaorgydexarscwdhwbwn
pm~to Me wen omw.
7. Is this a repair to an existing well: 0•Yes or ❑No 23.Sfta diagram or additional well details:
U(hla is a repair,a outknoavn wed rxmsbucOn kftmbbn end o;plshr the nature of You may use the back of this page to provide additional wag site details Orwell
the rapairurrder#2f remeft secilonoron the backofthtsform abmndonmeMdetalla.You may alsoattach additional pages If necessary.
S.For Geoprobe)DPT or Closed-Loop Geothermal Wells having the SUBMITTAL INSTRUCTIONS
same construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of 24a.For AN Wells•Submil tills form wilhin 30 days of completion Orwell om Arucuon
wells drilled: to Se�+�g: '
9.Total well depth below land surface: L (ft) Division of WaterReeources,brfornmMon Processing Unn,161T
For multiple weds list eB depths Ndfferent(axampk:-3@200'end 2@1007 Mail Service Center,Raleigh:NC 2TS99-161T
I
10.Static water level below top of casing: IfL) 24b.For Injection Wells:in addition to sendi4the form to the address in 24a ebove,
If wv3terhevel Is above cesMg rue'r• / also submit one copy of this form within 30 days of completion of well consbuclion to fire
fo
11. Borehole diameter: (D (inn.) O1Ning'
/► ) Division of Water Resources,Underground Injection Control
12.Well construction method: Air �CQ/-L Progrem.1636 Mail service Canter,Raleigh,NC 27699.1696
P.O.auger,rotary,cable.disci push,do.)
24a F,gr Water Semoly&M)g�lon Wells:In addition to sending the tome io the
FOR WATER SUPPLY ONLY address(es)above,also submit one copy of itds form wRdn 30 days of complaUan of well
13a.Yield(gpm): Method of Test: D t/ A construction to Um minty h%M department of the county where eonsWcted.
13b.Disinfection Type: rKe e IC Amount
Form GW4 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016