GW1-2022-02987_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD QW-1) For Internal Use Only:
i .
1.Well Contractor Information- F
Ja�1 ta 14.WATER TONES
Well Contractor Name FROM TO DBSCMMON
v V 4 &
NC watt Contiaotoc Ca:ti&oaaoa N+®6Q Mourmix CAM0r e
FROM TO DIAMBTBR CIt M MI MAT MAL
�G2--� �i L.GC��I�' �✓L�' _ O ft. � fL �` In- ...+'./1�
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CompanyNama I&DINERCASMORTtJBING dosedd
2.Well,construction
Construction Permit#: 21 — O FROM I To I DIAMEM I TMCKNM I MATMAL
LIM all applicable well consructlon pMu is(iz.UIC,Cormty,State,Variance,etc.) In.
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3.Well Use(check well use): R• m•
Water Supply Weill: 17:SCRBEN
Agricultural [3MunicipaMblio p R. To DrAMETRR star MATRRTAL
Oeothermal(Heating/Cooling Supply) 0<.'demtial Water Supply(single)
Industrlal/Commercia. DResidential Water Supply(shared)
i&GRODT P
lIrrijuition FROM TO MATMUAL EMM"CEMMM MEMODtk"OUW
Non-Water Supply Well: R-
Monitoring
14ection Well: ;>1
tt. ft.
- Aquifer Recharge DGroundwaWr Remediation 19.SAND1GRkV1lL]?A(XflfanD1kd1M
Aquifer Storage and Recovery DMinity Barrier ' FROM TO MATRU" NIM01)
Aquifer Test OStormwaW Drainage R- R•
_ Experimental Technology DSubsidenee Control tt. ft.
Geothermal(CltlsedLoop) Tracer 2&D GLOG attachaddidondsl�if
Geothermal eaten Coolin Return Other(explain under#21 Remadcs FROM TO OBSCR�TIox color aaiihoek eta
fit. ft. 11OaLcn
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4.Date wel(s)Completed: I " 1l"22— Well ID# ft. It. 4e g A t,-N� firt t
ft.Well Locatio�n,:/ ft. D fr.
ro tee: ft. ft.
Facility/Owner Name T— Facility M#(ifapplicable) ft. ft.
91N—UT ft
Physied Address.fib',and zip
21.REMAR>;8
County Parcel IdentifirationNo.(PIN)
Ob.Latitude and longitude in degrees/mhtntestseconds or decimal degrees:
(if well field,cue Wong is sufficient) 22, catl
3(� )7/ 737 N 7Oi, l/V 772— w
6.Is(are)the vrd(a) e:rmaneut or Temporary SiparkeofFem d weu co i Date
reps By signing oils'form.I hereby certify drat the weU(s)tear(were)eotrsoucred In accordance
7.Is this a to an weIl: Yes or O with 15ANCAC 02C A100 or ISA NCAC 02C.0200 Well Construction Standards and that a
!f this is a repatr.fill out larorvn well construction infornraion and explain the rauure ofthe copy of this recardhas been provided to the well owner.
repair under#21 remarks section or on the back of thisfam. 23.Site diagram or additional well detail
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 OW-1 is needed. Indicate TOTAL NLTU BER ofwells construction details..You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r��J 00 2ft.For All Webs: Submit this form within 30 days of completion of well
For nudtipie wells list all depths tfd&ent(erranple-3Q200'aand22@100) construction to the following:
10.Static water level below top of casing: ICJ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Servic6 Center,Rale%b,NC 27699-1617
11.Borehole diameter. (in.} 24b.For Iniection WeDss In addition to sending the lbrm to the address in 24a
12.Well construction method: �. above,also submit one copy of this form within 30 days of completion of well
(Le.sage,rotary,cable,direct posh,etc.)
construction to the following:
Division of Water Resources,Underground Weedon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636hUff Servke Center,Weigh,NC2769XI636
13a.Yield(gpm) Method of test Li t 24c.For Water San&&Infection Wells; In addition to sending the form to
9 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:/d 7W Amount: / f c+'r G[: completion of well,constinrxion to the county health department of the courtly
vrhere constructed.
Form GW-1 North Carolina Department ofEnvlmna=t d Quality-Division of WaterRaourms Revised 2-22 2016