GW1-2022-01458_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-D For Internal Use Only:
1.Well Contractor Information. `
Q 1 V7 �7 t ll 14 WATBR ZONES
Well ContractorName PROM TO DItSCREMM
ft. oft. perM111)
ft
NC wall caneaaeor celtiSaeNon xua6er
FROM TO IM r
D TBICRNESB MATERIAL
1�4EG• �►2 Pt�S � ft. A ft. In.Company Name
1&RMOffiR CASING OR TUBING cload4
2.Well Construction Permit#: FROM To I DIAMBrtdt I TMCKNM MATERIAL
List all applicable well construction perdu(1-WC,Como.State,Variance,etc.) % ( fL Y
3.Well Use(check well use): f1. ft. It6
water supply Well: V.SCRIMF
momAgricultural DMunicipaMblio U M To ft.
DiwM�>IIn.
Geothermal(Heating/Cooting Supply) ZPesidential Water Supply(Single) g, 8. f in.
Industrial/Commerciei Residential Water Supply(shared) IL GROUT 1
W 'on FROM TO MATERIAL EMHACRM]DlTM9W0D&AM0UNT
Non•WaterSupply Well:
Monitoring --Recovery ft. &
1weetion Well:
ft. &
Aquifer Recharge DGroundwater Remediation 19.SANDlGBADBL PACK
ffavoliceW
Agalfbr Storage and Recovery [3Salintty Barrio FROM To MATERIAL EMF`IACXMENrMM0D
Aquifer Test nstormwater Drainage ft. ft.
Experimental Technology DSubsidcnco Control & &
Geothermal(Closed Loop) ElTraw 20.DRII.IdNG LOG attach additional shy if
Geothermal Caolin Return Other lain under 621 Rema ks BROM ft. TO DESCRIPTION comr hudama6 wpekho&
4.Date Well(s)Complded: _ 2 Well ID# ft. it.
Sa.We11 Location: ft. ft. �ate, •�
ft. ft. •
ail"n�4►e1�t� �c�W- p
Facility/Owner Name Facility M#(if applicable) & 2 i 1.
nod Io d 1(�ylLkW �t Ulu ham ft.
Physical Address.City,end Zip ft. ft'
MIA) 6 43 :t � 21.RE11SAM
County pact et Ideati icati—No.
Sb.Latitude and longitude in degreealmhtuteslseconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certilieado
N W �?
6.I8(are)the weil(s) Permanent or 13Tel"rary signake o0ped well Contractor Date
By signing this form.I hereby cenVy that the wells)was(were)coasmttxed in amwdenc e
7.Is this a repair to an etiisomg wen: 99
Yes or E)NO with I5ANCAC 02C.0100 or ISA NCAC 02C MOD Well Consimcrimr Standards and that a
If this is a repab;fall out brown well construction informarlon and raplaln the nave ofthe ropy of this record has been provided to the well owner.
repair nnder921 remarks section or on the back.of this form. 23.Site diagram or additional well derails
8.For GeoprobeMPT 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: �� t�I I bEaTAL INSIItIICTIONS
9.Total well depth below land surface: (R.) y4a,For Ali Welts: Submit this form within 30 days of completion of well
Formultiple wells list all depths ifdiffawa(rsample-3Q200'and 2Q1009 constructionto the following:'
10.Static water level below bop of casing: Z (ft.) Division of Water Resources,
If rater level is above casing,use"•+" Information Processing Unit,
/ 1617 No Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 /�� (in.) 24b.For Infection Must In addition to sending the form to the address in 24a
�j above,also submit one copy of this form within 30 days of completion of well
(L.Well rotary,-l% method:- construction to the following::
(La.augey rotary.cebk,dirx:et push,etc-)
D1v1sion of Water Reson�rces,Underground bdecdon Comm!Prrogram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,RaIeigh,NC 27699L1636
13a.Yield(gpm) Method of test: 24c.Fbr Water Supply&Irrtection Weft 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 the county health department of the county
wht re constructed.
Form GW-1 North Carolina Deim meat ofEnvimnmentel Quality-Division of Water Reso— Revised 2 22 2016