GW1-2022-01546_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD QW-1) For Intemai Use only:
1.Well Contractor Informadoow.
14.WATER ZONES
well ContractorName FROM TO DISCRIMON
f'� cog 7/2
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NC WetI Co�matorCe[tificeti®Nnm6— 1* ri
I s
„ s11-c IJ i Ct S SitYL/ FsoM To nraMe�ein. TRaNeas 1 MnTeRrAc
CompanyNama
16 DOM MERCASINGORTUBING dosed-I
2.Well Contraction Permit#: FROM To I DUBOVEM I TMClaRss I MATEMAL
List all applicable well consA•ucdon permits(i.e.171C,Cmarty,Stole,ftfance,etc.) ft. ft.
3.Wel!Use(check weR use):
Water Supply Well: 174SMIEN
FRM TO Divmm s1.tYrsm mAnnAL
Agricultural icipet/Public D R. R. in.
Geothermal(Heating/Cooling Supply) GRestidentil.Water Supply(single) ft. 8. In.
Induslrlal/Commavlal DResidentlal Water Supply(shared) I&GROUT
IrriRation FROM TO MATRRiAL I EMPLACMEMM MOD&AMO
Non•WaterSupply WeR: R- R- 3 "
Monitoring fL R.
lWection Wes:
fsprHeaW
Aquifer Recharge �Growtdvvater Remediation
quifer Storage and Recovery SalinityBarrier FROM i TO PACK MATMU" MsrxODAquifer Test OStormwater Drainage fL ft.
15A
perimental Technology DSubsidence Control ft. &
Geothermal(Closed Loop) Tracer 20.D G LOG attach additional sheetsGeothermal calla Coolin Return Other(explain under 921 Remadrs FROM To nsseRmrloN tobr aoilho� eta
ft. ft:
4.Date Weil(s)Completed: �,j�_,� Yell IDlii ' —� ft.
5a.Well Location: ft' -
fc. ft.
Facility/OwnerName Facility M#(if applicable) R' &
Physic .City,and Zip ft.
21.REKARBS '
Cc" parca identifrcahanNo.(PR rOCB
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(iffwell field,me IMong is sufficlent) 22.Ce on:
G � / 2-/?-.21
6.Is(are)the well(s)GII(ermanent or 13TUVoraq MYnture if Certified Well CoMWr Date
By signing this form.r hereby aoYify that the wff(s)was(were)cmut wed lmaccardance.
7.Is this a repair to an existing well: nYes or a with 15ANCAC 02C D100 or ISANCAC 02C MW Well Conmuctlon Standards andthat a.
ff this is a rgpab:full out i wwt well aonmuction Inforn Won and=p/aln the nature of the copy of this record has been provided to the w it comer.
repair under#21 remffh section or on the back ofthfs form. 23.Site gym.additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Yon may use the back of this page to provide additional well site details or-weli
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells construction deWs..You may also attach additional pages if necessary.
drilled: MTTTAL IIYSTRIICTIONS
9.Total well depth below land surface: ) 24a.For All Wells: Submit this form within 30 days of completion ofwell
For multiple wells list all depths Jf dj,$erent(e=ample-3@200'and 2/00I constmedon to the following:
10.Static water Ievel 2`7 below top of casing: (ft) Division of Water Resonnoes,Information Processing Unit;
ffwwer level is above Dosing,use"+" t 1617 Mall Service Center,Ratelgh,NC 27699.161E
11.Borehole diameter..iL_� (ht.) 24b.Far Infection Webs: In addition to sending the form to the address in 24a
nn above,also submit one copy of this form within 30 days of completion of well'
U.Well construction method: ryes t i construction to the following:
(Le auger;rotary,cable,dua:tpash,etc)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resoureav,Underground LVection Control Programr,
y� 1636 Mail Servke Center,Relelgb,NC 2769XI636
13a.Yield Wm) Method of test —6 ")/f i *For Water Sook&Infectioa Weil In addition to sending the form to
/� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfecdon type: Amount: C Q&A-^QL5 completion of well construction to the county health department of the county
where tmm-tracmd.
FamrGW-1 North CudIiaaDe-w=tofftWrotun nWQuality-DivisionofwaterResovrees Revind2-222016