GW1-2021-00398_Well Construction - GW1_20211230

WELL CONSTRUCTION RECORD(GW-1). For Intemal Use Only:
I.well Cola f-tlon:
7d 14.WATER ZONES
Well Contra6tor Name FROM ToDI>SQZ�7ION
C� fi
Q / R R
NC Well Conti=W Certifi Number &UUTER,CASINNG for* OR LMR
FROM TO DiAMErFdt T®CICNES3 MAWAULL
ft- ft. in. t
��Nam 9 / 1b:. ,CAfiII�TG flRT1)BIDiG.
2.Well Consb coion Permit#:_L / / FROM TO I DUM TFJt I TMCKNESS MATERIAL
List aU apphcabir well construction permits(i.e.Wr—Comrry,State•Variance,era) R in.
3.Well Use(check well use): R ft is
Water Supply Well: '1'T`SGREEN
FROM TO nrAMErER SLOTSIZE I TBICKNrvz I MATERIAL
._ Agricultural pM lic O R ft
Geothermal(Heating/Cooling Supply) LIftesidential Water Supply(single) fL is
Industrial/Commercial [Residential Water supply(shared)
.. hTl ion FROM I TO MATERIAL EMPLACEMENT MEIHOD&AMOUNT
Non-water Supply Welh fL Q R 0 � �� �,� r /e
Hoeg []Ro-,y fL R
IC-othesmal
eelion Well:
ft ftAquifer Recharge ElGroundwater Remediation tquifer Storage and Recovery QSalinity Barrier FROM ! MATERIAL EMPLACEMENT METHOD
quifer Test' DStormwater D fLxperimental Technology Subsidence Control Reothermal(Closed Loop) Tracer •:36:•DRtSI.ING'.LOG. addtiaemia6eee: .
CMl1eI( lain wilder#21 Remarks) FROM TO DESCRI11 IO Ooion bards®,som/roek sta,em
R R
4.Date Well(s)Completed (Well 11D# fL
5a.Well Location: ft R
TJ` $ fL R
Facrlity/OanerName Facility]DO(ifapplicable) R R
l l U l/f,,' A/1/ j R R
Physical W City,and Zip R R
G 2LREMARTfS
j E
CountyParcel tdeffification No.(PIN)
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(ifwell field,one ld4ong is sufficient) 22.Certification:
N W
1,23 X21
6.Ware)the well(s) ermanent or Tempo;No
S*natum of Certifi W Contractor Late
By signing ihis form.I hereby certify d=the wells)was(were)consinrcted m accordance
7.Is this a repair to an existing wdL- DYes or with/SA NCAC 01C.0100 or lSA NCAC 02C.0100 We11 Construction Srandardv and rhm a
1f this is a repair,fill ord brown well eor muwon mfornration and erplaw dre natrtre of the copy ofd&record has been provided to the well owner.
reptirWider 421 Pent&*section or on the back of rldsfonn.
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land sutfi:e: © (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For md*k wells un all depths if 4t&:m(--1-V-e-3 00'and 2(n11003 construction to the following
10.Static water level below top of casing: r� (fL) Division of water Resources,Information Processing Unit,
111.B r level a diamaboveeter:
casing,rose +^ 1617 Mal Service Center,Raleigh,NC 27699-1617
Il.Borehole diameter Cm) 1/ 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method 0 /e,"r above,also submit One copy of this form within 30 days of completion of well
0-c.=*-.may,cable,5 Pam,ctc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test: 24c For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) above, also submit One copy of this form within 30 days of
13b.Disinfection type: i t l� Amount completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Depatmeot of Environmeaml Quality.Division of Water Reso aces Revised 2-22-2016

Jan. 29. 2018 10:58AM Env. Health No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW.I) For Internal Use Only: !!!Cootracto Inform It -- � c `Y- — — ---_ '
2,, < `l be cna�vaT>t uzoluuas.: ;=_
Well ContractorName MOM TO DFSCR�N
NC Well CoMeYor Cettificstien Nvmber �13.Gum CAS LYf1'OWWWWRAiei1F$el[4:OR= : f_"IfiStNb'.':i�':a:B`
FROM TO DIAMETER THiCI4YE33 MATERIAL
�errfLC O ", 12 34. 1
ilc-
C e .
:16JNNEIreASIHaOR'14i11i - ,—
L
2.Well Construedon Permit#: FROM TO I DrAM R TR[ MATERIAL
y/rfallapplicabfewd/cmurrrtertoepem�trt pe.f11C•Canary,Stara,Variance,ew) if. Irt In.
3.We11 Use(ebeek well use): n. rt' In.
i1rrigation
aterSapplyl NI: ; �6ROM ItoDUMETfrt' SLOTSIZE ICKNPSS MATERIAL
Agricultural QMunicipaUPublic 0 ft. R.Geodtemial(Heating/Cooling Supply) Residential Water Supply(single) ft. ILLtduatriat/Commtxcial Residential Water Supply(shared FROM TO MATERIAL WI1?LACFMEKMMU0Da:AMOUNr
Non.Wattr Supply Wait- O
Monitoring 13Rewvery R. R,
Injection Well: rt
:)Aquifer Recharge [)GroundwaterRemediation
1'A�SXIID/GR/iiBL•1'<CC ` F.ii"'REiBIb':c__:;a:o-,.�-"::=:�Y-:•—u- .. .,-.
AquifCTStorage and Recovery 13SalinityBarrier FROM TO MATERIAL I EMP(ACRMENrMrM0D
_ Aqu&Test 'r3StormraterDrainage n' fr.
Experimental Technology OSubsidence Control aL R.
Geothermal(Closed Loop)_ 13Traeer iQ:p G7OG"aifueli ad'dl''tiob:tiliieis[titecia'ai -_-_ _•�"y==`
_ Geothermal(Reuting/COoliegReturn Other ex lain under#21 Remarks YAUM TO OfSCR IOY afarhn*wshselYrock 1 —tot etr.�.
R ft.
d.Date Well(s)Completed:r�� Well ID# R 0 ".
Sa.Well Location: o a It - 1
11mlity/OtvnefName Facillp.ID#(if6"I=' bb� fL n'
n.
Physical Adamse,City,sad Zip (LS IL M tt
County P=A1 Men0cation No.(PIN)
Sh.Latitude and longitude In degrees/minutes/seconds or decimal 7 degrees: J
(ifwell field.one IatAong is sufficient) ee��/ 27.Certification: QAy jg g-
3 S.av'7aS5 N — 00/• A10 �a? W
6.Ie(are)the hvel[(s) Permantnt or QTemporary 9igaare<e ofeertified Well Contractor Dete
By signing this fora;1 hereby cer*(her the Mell(s)rot fi ere)emuatared At occotdaace
7.Is this a repair to AD existing well: QYes or o with IJA NCAC 02C.0100 or IJA NCAC 02C.0200 Well Coatintenon SiandaMt and that a
if this is o repair,011 ora knumv well earrtnttttoh rtlarrhation t0, &p1,MI the nuts of the oappof 01srecotdins been prottded roYhe nail owner.
repair under t21 nasals section or on the bock of tins form.
23_Site diagram or additional Weil details:
S.For Geoprobt/DPT or Closed-Loop Geothermal Wells having the some. You may use the back of this page to provide additional mrJI site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: S MNUTTALINSTRUC.f YA
9.Total well depth below land sodtaeer J 0 0 (k) 249. For All Well Submit this farm within 30 days of completion of well
Formufaple welts lift ail deyths Jdfferent Ikram plc•J@2M'and 2®100') construction to the following:
10.Static heater level below top of casing: ([t•) Division of Water Resources,Information Processing Unit,
ffvarer level frSam&Vw&use"+^ 1617 Mait Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.— '_ '"(in.) 24L For Inlection Wells: 1n addition to sending the farm to the address in 24a
�(� Y'i above,also submit one copy of thus form within 30 days of completion of well
12.Well construction method:
(i_a.sugw,rotary,cable,duecl pwb,CIO.)
construction t0 die following:
Division of Water Resources,Uncittground Weedon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636,Mail Service Centee,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test . 24c.For Water Sunaly dt Inlecdon Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to dw county health department of the county
where Conslrttcted.
FanoGw-1 North CaralsmDepanmeatafEe iroameoralQsliry-DivisionofWaterResources Revieod2-22-2016'
i

Jan, 29. 2018 10:58AM Env, Health No, 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W 1 Coatralufor!111710 : '
t2n:�vwzge zctllr�s.;__= s _i - fir:. :.-
e FROM TO DESCRWMN
Well ConeraetorNatx '
10 ft- fL
NC Well CoandYm CeMcalton Nvmber r.`.I6.011TMCASING' 6d tali ed M :: ' 6ii"'
/► i FROM TO DIAML'I'ER THICIMS AUTERLU.
— % R.
Co
- �3�?L 16:IIVNER'.CASI�YG}O1f;CliD1 . , eCoiid-lo '•.•:•@••��e=.=�o-=•''_=r
2.Well Construction permit#:^ -7 MoM TO DAM R 7V MWLUL
/,(sl all&pplieable well ea wmedon pemor Pe.WC,ComV.Srate,Variance,ern.) ft. th In.
3.Well Use(cheekwell use): n, tr, m•
Wuer Supply Well:
EOM TO DIAMETER SLOTS TnIC ATFA7AL
_Agricultural DMunicipal/Public 0 o. rt. I m.'
Geothermal(HeatindCooling Supply)residential Water Supply(single) ft.
_htdustriallCommcroial ❑Residential Water Supply(shared)
Irfation OM To MA AL WAVILACIEMEMMEMID@AMOUNr
Non-Water Supply Well: Q n. aQ re ` i 4 `fl1
Monitoring ❑Recovery R R.
Injection Well:
h. A. .
Aquifer Recharge [Groundwater Remediation 79 -. ,
ilNIHGPAVB1 PACK' fit'"'u61e;:s;.��;t,•t-
IGcofAquifer Storage and Recovery C)Selinily Barrier FROM TO MATERIAL Eb1Pl t MMOD
ficrmal
AquiferTest 08tormumterDrainage ft.Experimental Technology CISubsidelice Control tLGeothermal(ClosedLoo)_ [3Treeer :"20.p cIt�G aif�eudttioueii?i'e`W.R.:ecaa(Heoting/Cooimg Retrnu Other lain under#21 Remarks FROM TO DIESCaIPrIONcolor.hndnnh nIVrKk O R 30 R, an
4.Date Well(s)Completed: WelI JD# 301L y/ B.
SL Wall Locatiom Vl: S.2 it r
S40tmn 9e2 ?00 f.
Facility/OwnerNaate FaciliwIng(ifippticable) R n.
RFrpfE '
Physical Addm d.City,add Tip 2 t6
C—ly ParcelUen"catida No.(PIN)
Sh.Latitude and longitude to degreestminutealseconds or decimal degrees: G ",,.
(iewetl field.one tadtong is sufficient) 27.Certification: 46 7� �-
3 s_ 31 sr am N - 81.a07163IdUL !AJ
6.ls(are)The wells) Permanent or QTemporary 9ilprure o enilied Well Coneactor , Dato
By rigging thif fob I hereby m*thrir the rrell(f)%w(kere)ewutmeted ht occordWee
7.Is Ihfa a repair to an exhting well: Yes or N with 15ANCtC 01C.0100 or ISA NCAC 01C.0200 Well COAnntarlan8farWx*and that a
(f this Is a tup&h,fIp ord Anasm well eanerruedan Inf&Wh'on&adesplam theWIM of die Gopy of rhrt moon/hes baanprowded to the wit owner.
repair under#21, rls seedon or on the beef of IMs famt
23.Site diagram or additional welldetatls:
g.For Geoprobe/M or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or Weil
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SIIll UTTAL INSTRUCTIONS
9.Total well depth below land surfaces .100 A) 20. For All Wells Submit this form widiin 30 days of completion of well
FoxnwJ11ple wells J&rarJdVhx;fdf/erenr(example-3(dy2M'md2®100') construction to the following:
10.Stadc water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
4'warer level is&bore emir&use"*" 1617 Mail Service Cinterr,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24L For InleetloR Wells; In addition to sendutg the fannto the address in 24a
above,also submit one copy of this Than within 30 days of completion of wall
12.Well construction method: Y, construction to die following:
(i.a augu,rosary•able,dutxt purl4 eloJ "
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cc'nhi•,Raleigh,NC 276991636
C i
13a.Yield(gpm) 7 Metbod of test: . 24e.For Water Sunnly Br IDlecdon Wells. In addition to sending the form to
the addrms es) above, also submits one copy of this form within 30 days of
13b6 Disinfection type: ��r Amount: za e&A-s completion of well construction to!the comity health department of the county
where constructed.
FormGW-1 North CamilmDepartmedt afEdvimnmeotel Quality-Division of Waw Acsotacas Rovisod 2-22-2016

Jan. 29. 2018 10:58AM Env. Health No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
Contracto IDformatlo
��1� !�l�� /C t�v.►Tge:zcji<t¢s.;_a�FR_:�- �;�,::�;-. �--_=_
FROM TO Otscairnoiv":: may,WdlCofivaetorName Ysoft TOP, S �I•/
- �1sa" /R• m
NC Well Comae or Certification Number
R16:.QU'1'glCt'.MSLKr3' ...rnidli-diised_..lb
i FROM TO DIAMETER TEt 9
b � I��l�_c1 �l �er�f4C S ft. ia- VcG
CompaagN a --309 MGM a6>N TO DrA MATERUL
et�tt.easl�caoncetlDtN�:...-t Q,+��:er�ad�•too' '-'�"'. '--� :.."
2.1Ve11 Construction Permit#: TNt
Lfrrall i;wjcablewell emurnucaonpertnru#.e.UIC.Couary;Stare,Variance,ex) R. R. In.
3.Well Use(ebeekwell use): n' R' to
Water Supply lweu:
FROM TO I DIAMELM I SLOTSMC I TLIC FSS MA G
C _Agricultural QMunieipaUPablie R. R m•
l Geothermal Mcatittg/Cooling Supply) idential Water Supply(single) R, fL
_LtdustrieUCommercial EI) esideatial Water Supply(shared) ------------
Irti lion FROM TO MAUNAL WMACEMERNMEMOD&AMOU"r
Non-Water Supply Well: O n. 3? ftd� Lin,
Monitoring ❑Recovery
injection well: h. R.
:-)Aquifer Recharge OGmundwater Remediation _
:19:.SiIPJ11/G11i�VEL•1.XC p.....heiUle' rs,�.-;,.,�."a�<=•ti:.»-�,..'•--.=:�^:':�
Aquifer Storage mid Recovery 0salinily Harrier FROM TO MATERUL uCIMER MerRon
I
AquiferTest _MStormwaler DrainageExperimental Technology CISubsidence Control U R•Geothermal(ClosedLoo)_s.. V6- ,�L
DESCaIPrroY aler,bndneu,sotMM ' etc.
Geothetntal 'ng/Cooling Retmn > Other ex lain undertY21 Remarks 4.Date Well(s)Completed: W well ID# .sa Well Location: / 11ZzZ�� %
Famliy/OwnetNam FUMY WX(ifoppticable) It.
Phrical Addrms City,and Zip ft. tE
Couay pe:celldentitieatioaM.(PIN) 'Ni
ttQr Ir�t�� .;'► C.
5b,Latitude and longitude ID degreealmiautes/seconds or decimal degrees: /
(ifwall Bold,ono Isf/long is sufficient) 27.Certification: �V j�-
3 C—. 3_lb 0/S N - • 0.2:F-2 � w
6.la(are)the tvell(s) Permanent or OTemparary SignmrcortertilkdWellContractor Date
By rig»ing tins/orror,I herby certpy Char rite well{f)x»r(kereJ cau/nrereJ fi oecosdonce
7.Is this a repair to an existing weil: OYes or with 1Se NCfC 02C.0100 or 15A MUC 01C.0200 Wdl CoAnnicaon Slartdott:ts and that a
((:air Is arepah Jtf!pialnotruwdt eontsnatiaa tnfaratarion#.o
M the Main of the copy ofthis avoid has been protfded toltha well owner.
repair u aAre2l.enrant:section oron the bael•ofthrifann. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBRR of wells construction details. You may also attach additional pages if necessary.
drilled: '/ a SUMITTAL INST'RUCTItZNS
9.Total well depth below land surface: "F- (M) 24a. For All We) Submit this form within 30 days of completion of well
Formuprple wells fat all Ae&i(dij/event(e a*e.3@200'atd 2@100') construction to the following:
10.Stifle water level below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit
ffwarerIml tsabmcruhr&we"+" 1617 Mail Service Center,Raleigh,NC 2709-1617
1L Borehole diameter. (IR.) 24b,For Inlecllon wells: In addition to sending dre form to the address in 24a
f^Y I above,also submit one copy of this fbmt within 30 days of completion of well
12,Well contraction method: M construction to die following:
(i.m augm rotary.cable,dirt:et push,eto.)
Division of Water Resources,Underground Injeedon Control Program,
FQR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centee,Raleigh,NC 27699-1636
/ c
139.Yield(Epm) < o Method of test_ . '�Gl 24.For Water Sunmty&Inlecdon Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: �!r Amount. completion of%ell construction to the county health depanment of the county
where constructed.
Form GW-1 North Caotian Depusmew ofEaviroarmatal Quality-Division of Water Rraomase Revised 2-22-2016

Jan. 29. 2018 10:58AM Env. Health . No. 6711 P. 1
.S'
WELL CONSTRUCTION RECORD( W-1) For Internal Use Only:
1.M cto Ihtortmttio :
Wdl elFROM TOCContractor Name on / /S R 96 1 3
073
NC TUCoMMNrCCrfificafionN=bcr igd:lOUTLWCASL\IIi'fiiil Wdfed4 lls'OIt = f>i' I bible'rl-MMM N.':
i FROM TO nrAMErER T1rfCTLVM MATERIAL
C a
-l ✓f ANNER' X OIt l�At
:- . : ":lii dl;ddietildd sty+rr
2.Well Construction Permit#: FROM I TOoft
l fst ell applicable wrll cmurruetion permtu A.e.fllC.County.Slate,Var craw,
3.Weil Use(check well use): n.
1",
iser Supply 1Ve1L• r1Z 8 gM�'`•- - a,:.�::��=_ ..,.;�.._:�,.�,.;.,.,�.�,.� �.---_—=_
FRol ,rp OWHErfrt S oTStr6 Tts CItN Lit
Agricultural MunicipsUPnblic 0 0, ft iu
Geothermal(Reating/Cooling Supply) idential Water Supply(single) p n,IndudrieUCommercial dResideatisl Water Supply(sharod)Im lion FROM! TO MATE AL EM LA EMMEMOD&AMOUNreon-Water Supply Well 6 fr. a' "' , ! c�Monitoring ❑Recovery ft. R.
jection well:Aquifer Rechargo aGmundwater Remediation191.SAHIIIGRANECrAquifer Storage and Recovery aSalinity Barrier FROM TO MATERIAf.Aquifer Test -08tormWeterDrainage n' p•
Experimental Technology Subsidence Control rLGeothermal(ClosedLoop) aTraeerGeothermal Reating/CoulingRentrn Qther lainunder#21 Remarks) FRoat TO DfSCatvrroN ular,hminear,setYeock ,�etc.
0 It O rt.
4.Date Well(s)Completed: 7 1 well ID# 30 n O r' 01 r
Sa.Well Locatiom ^ Il t9 tt SOF !
Mid
Vite
Facaitylthvnermaw Facility IDA(Wipplicable) R ddW
tt
r
M ft.
Pirysiml Address,City,add Tip �Lf/ 0 p IG
Gin
County Parcel Iden"catim Na(PIN)
5b.Latitude and longitude to degreealminutes/seconds or decimal degrees: / ^,
(irwell geld,one 120ong is sufficient) 22.CertiCseation:
36,3110S87 N -S/.060a90 W �L�
6.1s(are)the well(s)a6Permanent or QTemporary 91pinue o ertilled Well Conascror Dili
by tigtting this forat.I hereby cer*rear the Wfi t)uW(Mere)eavowled in occohtwee
7.Is this a repair to an existing well: apes or MIo with ISANCtC 02C.0100 or IJAX-C 02C.0200 Well ConrinletlonMath4m*and char a
Orbit is a rep&,f!U otabrawnwdl eanitrttaim Mforetaion andetplM the namro of the copyof(his r )d h.as oven prowdW ro"I&)Fell owner.
repair under 92I namrks recuon or on the backof this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed•Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wens constriction details. You may also attach additional pages if necessary.
drilled: !� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` O (tf•) 249. For All Wells: Submit this form within 30 days of completion of well
For mtt►aple wens fist a►l depda jdi,Dlre a construction to the following:
10.Static water level below top of casing: / (ff•) Division of Water Resources,Information Processing Unit,
ywarer[ever it above anw&tag'+~ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (Ip.) 24L For Inleetlon wells; in addition to sending the fonnto the address in 24a
above,also submit one copy of this lbrm within 30 days of completion of well
12.Well constraetlon method. construction to the following:
(Lm aagcr,rotary.table,dimdt push;eto.)
Division of Water Resources,Uudetgeotmd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centee,Raleigh,NC 27699-1636
t
13a.Yield(gphn) 30 Method of test. 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
131L Disinfection type: ti Amount: completion of well construction to tho cowtry health department of the county
where constructed.
FormGW-1 North C=h=DcpaM6 tdMinim-wenmlQusliy-DivisionofWoterRrsomces Revised2-22-2016

Jan, 29. 2018 10:58AM Env. Health . No. 6711 P. 1_
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W 1 Coatracto Intormatlo
�6
FROM TO DFSCRWMN _
WdlContraetorName fOSift
m
c7 R.
NC Well Coma or Certification Number 115,.1MCA IM tn0ioid -eel"'c1b:01t - '"M!
mom TO DIAMUER [CILYFSS MATEIUAL
-� vc.
- ' ��O� �;16INNER'.C'AS1iYGF.Ott:L44A1I4G:•...Iherfuuat; oiraloo v<�;w�e"�-r-�•�:,�.•
2.Well Construction Permit#: a, o Di R II[[ MATERIAL
/,ft1 all apppmb/e well eatutntotimr pennlu 0.0 WC.COuary,Sra/a;Yarnnee,ern.)' h• h 1°
3.Well Use(checkwell use):
WsrerSa l Well: �Ja2-S _:� �..r. �,�sa F_�_ _�
Supply MOM 70 D ET LOTS1rE Tn C -M UL
_Agriculture! Municipal/Pablic D.
Geothermal(HeatingfCooling Supply) esidential Water Supply(single) h• fL tn,'
_IndustrieUCommercial DResideatiol Water Supply(shared) :4
Irrigation OM TO MA AL: EMPLAC¢MMTmEnm&AMO
NOR-Water Supply Well: Q D. 3 rr. 4 ��
Maniterritig ❑Recovery
Injection Well: tt
_ Aquifer Recharge OGtoundwaterRemediation
9rSAiYD/GRX?YBGPACk' Fii"sea'Ie's-== .:, ....
Aquifer Storage and Recovery OSaliniryBarder m TO MATERIAL 1,A MEN[MUROD�~r�r
_ Aquifer Test -QStormwalerDrainage R• h•
Experimanual Technology ]Subsidence Control EL h•
Geothemtal(Closed Loop),. OTraeer :•20.:D �7AaG"aitneli all Itiohet'vfieeh Rjrec� :': :` ""°•"""`'�
;:.. 1>nloM atscaurtroN pler,n.,,u�r.>o±trr�k in
_ Geothermal(Heoting/Codtmg Return Other Inin under#21 Remarks D ft 5 fin
4.Date Weil(s)Completed: well ID# 'L Z 110
h' O
Sa.Well Location: if 0 ft I S tL e-1
;0 51', i s 155 �
Fam'Iiry/OwnerName Facitityro0(itippticabb) R n.
I A- V 0n4 r4 L.109
i Addrost,City,aad Zip / tr !L
61&54On
Cm1aW Parcel Idemification No.(PIN)
5b.Lafitude and IoDgltude In degreosfudautes/seconds or declmM degrees: / R(irwall Held,one larilong is sufficient) 22.Certification: p�V _
, S.a25o353 �N -S/. D SP7/ � w
6.ls(are)The well(s)OPermanent or OTemporary gigoatme o ertifsed Well Contractor Date
By signing ilds John I herehy cerlpy Aran the well(r)war(mere)eotsnucted at accordance
7.Is lids it repair to on existing well; Ones or hUo wah 13A XCAC 0IC.0100 or IJA NCAC 02C.0200 Well Coannrcrlon SfaacWdi and that a
(/fAis IS anpalr,JJAolalaamrWa t eannnra O11 tnlfar W1i6n and aiplaai the saran of the copy ofdtu mcmd nor been prodded to the ever/owner.
repair under all ten arb section or on the bad offt forea. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may on the back of this page'to provide additional uail site details or Weil
construction,only I GW-1 i,needed. Indicate TOTAL,MJMBBR of wcUs construction details. You may also attach additional pages if necessary.
drilled: SU11 N UTTAL INSTRUCTUONS
9.Total well deptb below had surface: 'V9,0 O VQ 24a. For All Well Submit this form Within 30 days of completion of well
For .mtdaple wells hstall depJ6 ifdipeseat(Oatnple.3@200•ond 2@100') construction to the foltowing:
1
10.Statle water level below top of easing: 3 (R•) Division of Water Resources,Information Processing Unit,
/fvmar low/is abve cmtng we"+" 1617 Mail Service Cchter,Raleigh,NC 27699-1617
IL Borehole diameter.�(ill.) 24L For Uniteltan Wells: in addition to wilding die fonnto the address in 24a
about,also submit one copy of this form within 30 days of completion of well
12.Well construction method: _ r I construction to die following:
(La auger•rotary,cable,direct puss e1c.)
Division otWater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t _
13a.Yield(gpm) Method of test. . 24c.For Water sannty&Inleetlon Weida: in addition to send' the form,to
`/� the address(es)above, also submit ii
co 1I n 0 days of
13b,Diddectlon type: �L(r Amount: Z completion of well construction rot Ue the county
where constructed. 1 -FomrGW-1 NonhCMt�fl��ea a atEdvimmeamlQtaNy-DivisionofWowResomeesl DECC � ® 2O�RavkW2-22-2016'

Jan. 29. 2018 10:58AM Env. Health . No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Intemel Use Only:
1.2 1 Comtracto IDtormRdo :
t<.1ii:�VATB -ZONPS.,_��..:.:.,�:y:. •z.- :.<.,:..,.�:.»:.,.::;:::..�.:•rc-�T...._;�s::.:.= '
"Q mom TO DFSCRIP770N. --
WdlConuactorName 40 R' 017 11 v
NC Well CoarseYor Certification Number id.0)71EI1 CilstNti'folrmaltltasid "1ts:OItbENElt f ii Men �'in a:' ,.,::
FROM ro DIAMETER TH[CILYESa fERIAI.
• R [00 rL J7 V C_;
.�6c1NNSIt.CAti]i9Q;O1B'CiiDBNC►� ..-Ihern"rat<eriisi+dlbo• ""'V^'"'_,,,_.�.__ .
2.Well Construction Permit N.-, 3 / FROM To orAmm ft TMCkNEO MATERLBL
l kr all applicable well eatrnn,edon penntu 0.e.IIIC,Camry,S4are,Yarlrmce,arc.)' R. R.
3.1Ve11 Use(check well use): R. tr. In.
r12•:8t�t$EN=`r °_ . tom :_.: ^..-% ' _ s=< ':
JA
erSupply%Vell: FROM t0 EM SLOTS ThICKHMS MATERIAL
gricultural Municipal/Public 0 R. R. in,othermal(Henting/Cooling Supply) idential Water Supply(single) R. Rdustrial/Commereial [3Resideatial Water Supply(shared)
tion rAOM TO MATERIAL zmPLACmm.mLTItoD&AM UNr
-Water Supply Well: Qft. Orr.oni Recovery R. R.
cdon well: h.
quifef Recharge QGtnundwater Remediation7A4A'PJli1GPAVEEPACK' Fa"••BFlililequifer Storage and Recovery OSalinityllarrier PR TO MATERIAL EMPLAC104WMITAOD
quifcrTcst C)SIormwaterDrainage rc R•perimental Technology r3subsidanceControl eothermal(Closed Loop):. OTracereotbermal Reatirrg/Coaiog Re Other lain underti2l Remarks) pAOe[ TO OrSCRIPrroN atom,turdnear,safytak see tic.)
do R9 D R.
4.Date Wags)Compleud: 1 well In O � n ani
Sa.well Locations Zoo h (00 R. VIA&LA!
� ear - � �•
Fac7iry/Owner Name Facility 1V#(itipplicable) 2 0'
/00 9 11'O A 0'We �l 'a elm,le—k 2 n.
Phy/s�icist Addrast,Cit,sad Zip IL ft.
County Parcel Mesei6estion No.(PIN)
Sh.Latitude and longitude in degreestmioutedseconds or decimal degrees: ^�
(ifwall field.one lidlong is sufficient) 22.Certification: 16
35-. 3V0&gF/ N — 91 .O9 Fro 5 Wlak
6.IS(are)the wells) Permanent or OTemporary Silimiure,o emilied Well Contractor i Date
By slgrdng tldi Jane I hereby cer*that the v0s)ems(were)cottsmraed of occotdance
7.Is tuts a repair to on t3isting well: Yes orft````��•�o with 1SAXCAC 02C.0100 or 15A NCAC 03C.0200 IFe17 CoarneatenStaader&and that a
(/merit Ij a rspat►,f1p am Imawtr wdt earsrncbon Infaradrarn espfaas the rtatare aJrhe caPY oJrhrs tecotrl hat beau protvdMro The tacit owns'
repair urger a21 mwrb section anon the W aftMsforaL 23.Site diagram or additional wel!details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bests of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL,NUMBER of wells construction details, You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surfaces In•) 249. For All Well Submit this form within 30 days of completion of well
PoF inptaple wefts Jrsrad deprhr ildJ/erenr(e a*e-J@2W'and 2®I00) construction to the following:
10.Static tyaler level below top of casing: �a (R) Division.of Water Resources,Information Processing Unit,
/Jwarerlevel it above agars too"+^ 1617 fait Service Cehfer,Raleigh,NC 27699-1617
11 Borehole diameter. (tn.) 24b.For Inlection Wells: In addition to scrid'usg the farm to the address in 24a
above,also submit one copy of this fbtm within 30 days of completion of well
12.Well censtruellon method: A0 r construction to the following:
(i.c.auger,rotary.cable,drral puA6 eto.) .
Division of Water Resources,Underground Injeedon`Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ccnteir,Raleigh,NC 276994636
c
13a.Yield(glen) �t� Method of test. 24c.For Water SunDly&Inlecdon Wells: In addition to sending the form to
the addresses)above, also submit one co rBFt�of
13b.Disinfection type: 4 I t Amount: a tt completion of well construction ro`this coon Ith n 66 my
where constructed. D EC 3 0 2021
Form Gw-1 Norte,Carolina Department aMvirnamenral Qrmliry-Division of Water Resomms Revised Z42-2016'
IJW'SECT e