GW1-2022-01419_Well Construction - GW1_20220124

Jan. 29. 2018 10:58AM Env. Heal th No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W Contracts �ID/to�t,Tm fi��"a'' ' r�Vll,! ►/�6 /L t`]9:SVATB �2Ol�t _-- ':—'s�'-'�_�_�'��------ ,s:.��;r.'..:�t�r�z�_.
sitOM TO _?DESCRIPTION
wen P-ontractorName 0 n• 100 tL ps Pm
�eZD e`Z'f O tr $ 7/7r7
NC Well Comtae-CeMeirionNumber r.` FIEICGISINCi:(6itmidt[<6fid=wells:Olty1NER` fii"h'bbt
&,Wd Se l'-l1 FROM
uatvEa.easlNc�vx�rttn T
ComyaagN me _MOMS HATERLAL
2.Well Construction permit#: 3 3 PROM TO olAmmit I TRI02ma I MAUPJAL
list all applicable well cotin e6on perh>tis As.WC.County.State,Yorinnce,etc.) tr. (I. In.
3.Well Use(cheek well use): n• h• in.
W ter Supply Well! -
FROM �I DiAMETCR :1 SLOTSIU I-THICKNESS I MATERIAL
gricultuml QMunicipaypublic 0 ft.
Geothermal(Reating/Cooling Supply) [Residential Water Supply(single) n. rt
Industrial/Commercial 13ResideatialWaterSupply(sharcd)
Irrigation EAOM TO MATERIAL UV CFMEM bIEMOD a AMOVXr
Non-Water Supply Well: 0 n' 02 S m ` , `yU
Monitoring Recovery R. It.
" 7njectlon Well: f, n.
Aquifer Recharge []Groundwater Remediation
Aquifer Storage and Recovery 13SOlinity Harrier FROM TO MATERIAL E IA aMENrM OD
_. Aquifer Test OStormwalerDrainage
tt
Experiments]Technology Subsidence Control n n•
Geothermal(Closed Loap),. [}Tracer i 20 A CIbCG•IAG eitael;addttioliaiaFeetrT[t+ieasi"_=_'>`=`y"L 
— Geothermal(IleatinglCoo�lin Renun Other ex lain under#21 Remarks FROM TO OaStlt ION alor,huanesgsatYr°ck iar tlr.
O n O ft )m Cho
4.Date Well(s)Completed: -cza well IN 70 IL 5 n
5a.Well Location: 1� 5 h d ft. tan Yte.1
Faeilii/qw efmaw Facility lD9((fiyylicable) R n.
60/ cAa j ?,,Z5,2 .AetirA lj- it n.
Physical Address,City,add s g Sv%n{h, N.0. a 8o!FG n• M
h _...._.._.__._.. .« _
Coualy Pucel Idenacadaa No.(PIN)
5b.Lafitude and longitude in degreed iniauteslseconds or decimal degrees: C
(ifwell Md.one lartlangissuffident) 22:CCeertification:
3sa0y fit 9 N — V,30ASo W &it
6.Is(aTe)the tvell(s) Permanent or [Temporary Silimmm o9tatified Well Contractor Date
By signing this fart I hereby eerrrly rhos the wells)war(roe)eolufteled A:accordoaea
7.Is ibis a repair to AD existing well:- E)Yes or No with IJA NC4C 02C.0100 or 1JA NCAC 02C.0200 Well Cononletion Standouts and that a
((this is repot,Jig ant kwust wdl coanrucrioh htfamathga ax etplam the nalme of the copy of this mewd has been p oifdedto the well owner.
repair under e21 reruns section or an the back of rhfsfmL
23.Site diagram or additional well details:
S.For GtoprobeM PT or Closed-Loop Geothermal Wells having the dame You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 iv needed. Indicate TOTAL NUMBBR of wells construction details. You may also attach additional pages if necessary.
drilled: ry`, StMM=AL INSTRUCTIONS
9.Total well depth below land surface: d T 0 00 24a. For All Wells. Submit this form within 30 days of completion of well
For mulaple wells 1W all Apda ij fjerear(w?nple-3(2M'and 2@100•) construction to the following:
10.Static tyater level below top of cAsing: Division of Water Resources.Information Proeesstug Unit,
Ifwarer level is abma easing we"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Barehols diameter. (in.)
Zdb.For Inleellan Wells: In addition to sending the Earn to the address it 24a
Avr above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to die following:
Q.&auger,miry,sable,cited push.eto.)
Division of Water Resources,Undergrodnd injeetton Control Program,
FOR WATER SUPPLY WELLS C ONLY: 1636 MMil Service Ceatei,Raleigh,NC 27699-1636
r
13a.Yield(elan) 30 Method of test: 24c.For Water SunDty&Inleciton Wells. In addition to sending the form to
the addreas(es)above, also submit one copy of this fore within 30 days of
13b,Disinfection type: Amount: C completion of well construction to the county health department of the county
where constructed.
FormGW-1 Nonh CarolinaDeputmem ofFsvuoamestal Quality-Division of Warr Resourees Revised 2 22-2016'