GW1-2022-00869_Well Construction - GW1_20220107

•WELL"CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Weil Contractor Information: �j e
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Wel[ConuaetorName FROM I To DESCR�I4QV 1
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NC Well Contractor Catification Number 7 1
Y151:OUTER(.h*SING s fii`in 7n ER
FROM TO Dmmff THICKNESS MATERIAL
lard . .. Lr�� t
mpanyName ® �„ tL In.
a 111a1Fdt CASING OR:TUBING'
2.Well Construction Permit*:. 7 FROM To .DUMEM THICmum H&TERML
List afl appikabk well cont&ucdon permits(Le.NG County,State Vwfanca etch ft. fL In..
3.Well Use(check well use): & In.
ppb'
Water Su Well: �B•17.•Sti1tE13isi:�tt<;'xti;.+sl•.'�.;a.+ i,3F�:ilti}Ni{i��F:u°;a:td Y `'��:5 �'��;t 'w ;i;:;_�
FROM I TO I DI AMM I SLCYrSEZE I T111CWTESS MATERIAL
.. Agricultural ElMunicipsl/Pubilc . 0 is to;
.. Geothetnal(Heatmg/Cooling Supply) JoResidential Water Supply(single) rc & In.
Industrial/Commercial [)Residential Water Supply(Shand)
,On x18.°GROUT����i`��R.•;7.:"st�i�i�f�.x:t�.;,�i:a�"':s"1!,^nJ'sf'):'7�?z:�1eY"S.'e'p'• �•+^Ss�ii�:�ii
FROM I TO MATERUL N EW1ACEb1MKr ODB'AMOUNT
Non-Water Supply Well: ft. it
Monitoring 01tecovery, ft.
Lgjection Well:
Aquiferitecharge 130roundwataltemediatioII ?19:SAPID/GRAVEtiPAl3IC A'"IIeiible r�+.sz: "
niferSto and ;•
M Recovery [3SalinityBarrier FROM:" TD MATERIAL ZMMCta,I0rrb rrHoD
AquiforTest j3StonawaterDminage It, IL
Experimental Technology 13Subsidence Control to tit:
Geothermal(Closed Loop) [3Tmca f2A:DRiLLWG LOG'itfiW ddiffi d1bRts itrieceva
Geothermal Cooling Return Other( lain under#21 Remarks) FROM To DFstaemrtox eotor twd sow�ode
d d IL ,
4.Date Well(s)Completed:: Nell m I n' .0 S'" ft.
AL
Sa.AA Welt Location: !�Ian n o y o ns f ra��%c�1 ft. c IL
ra od
Faclik/OwaerName _ FacMW 11M.0fapplicable) tt. • L
Pl zkWAdMesa,C1W andZ%, R. ft. ;
Q� 1 s 62IFRFMARKS
.��,1 .4.4 /d h • �ti'�ITi7::i47'+r�dl:",�.,!*i#.�%�ha r�iis:Y�';YrY s�.�.±s5:y�tW`5'.•��'�:5�>{M�.,; `��`�{
Cona9' ParcelldearfficafouNc(PAN)
5b.Latitude and longitude in de 'gt grew/minntes/seconds or degreese
0fwell field,one Wong is sufficient) 22.Certification:
6,Is(are)the weli(s)MI rernument or Temporary of aUGoatraetor Date
�,,� By 34mh g•Ws jbr^I hereby core that the,wdl(s)wear(were)eontrucied N accordance
7.Ls this a repair to an existing weI1: OYes or l�tn adth 15ANCACO2C.0100 or 19ANCAC 02C.0200 Well COuirucamSOXAVdrOrd that a
lfdtr Is r4wfr,JW out brown well eonstruedonWommdon and erpkfn the nature ofew eWofifts-umdharbeen p vvldad to the wd1 ownu:
repak under#21 remark secdon or on the backojthfsfornL
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 bite details or wen.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if neceisar.
drilled SUBM11TA1;INDUCTIONS
1 •
9.Total well depth below land suitace: @Zg (it•) 24a.For All Wells: Submit this form within 30 days of completion.of wen
FarmrilUple welk 16t ail depthsljdfgenara(aramp/e.gQ20C0',Ord l(�l construction to the following:
10.Static water level below top of casinglfw , es;7 C� UP Division of Water Resourc Informations Processing L%%
11.B evl:above�*hr&rue"+; tor r 1617 Mall Service Center,RoMpANC2749961617
Borehoo le diameter. . � L (�
246.For Infection Wells: 1n addition to sendi0g,the foun to the address in 24a
12.Well construction method:_ .r�) ) "ei root One copy of this fort within 30 days of compledon•of well
Cr a anger.mtary.eabt%dared push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: DIAS Ion of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699=1636
13a.Yield(gpm) 3 Method of testa L r , 24c For Water Snooiv&Intectton Aft. In addition to sending the farm to
the addresses) abov% also submit one'copy-of this form'within 30 days of
136.Disinfection type: c.hnhonnt:_7 a it completion of'wall construction to the county health department of the county,
where wastrncted.
Form GW--1 North Carolina I)Wrimmtof&vbonmentalQuaWy-Dlyfilon of Water Resauces
• � .Revised 2-22.2016
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