GW1-2022-02991_Well Construction - GW1_20220302

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WELL CONSTRUCTION RECORD(M-1) For bftmid Use Only:
1. R Contractor Information:
1-L 9VATER ZONES
Tel!Conic*rName FROM I TO DISCRIIION
IUPt' log
ft.
we Well
,C/oatrmEerCcdSe�im�— 'GM aril�
l/ y F�� � j/✓ ��( �s 1� ' (/ FROM TO DUMB= TEIICffiyV�B98
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tt. s. in.
CompaiiyNama N o 0�C v�
16.]NNERCASINGORTUBING Aned4owl
2.WeR Construction Pea'mit#: FROM To DIAM UM TMCKNM I MATERIAL
list all appficabla well COMIMCdon par ts(Le.19C,County,State Itarlmrce,etc.) & tt. is
3.Well Use(ehwkwell use): fit. B. in.
1`�Irrlzfttion
ater Supply Well: .17 SCRMN
FROM TO DrAM1MM RM MAIRMAL
Agricultural 13M�_�_., aMblio O ft. fa
(3eottertnd(Heating/Cooling Supply) DRd Midentiai Water Supply(single)
ndustrlallCommerciei Residential Water Supply(shared)
1�tRIODT
FROM I TO 1 EMPLACEM ff OD&AMQUNr
Non-Water Supply Well: 0 60 Q R-
Moni tg ft. t}
bdection Wen:
ft. ft.
Aquifer Recharge [3GmundweterRa a ietioa
uifer St 1S►.SANDI�VBL PA k -
JAquifer
Aq orage and Recovery 133adurityBanicf tutoat To MATMUAi hnt�tA NEW oD
Test OStomtwaterDrainage
-
Experimental Technology D ttbsidence CoMml & ft
Geothermal(Closed Loop) Tracer 2LDRMU M LOG:attaehadditionishe:isR
Geothe»ai Coolin Retnm Other lain under#21 Remarks) FROM TO DESCWnON dolor bmda soh kv&
M M
4.Date Wells)Completed: _9 Jam'• • WeRM# M
so.Wen Location. R' 6
& %
Fac' 1/O�wneDrI3ame Faci*M#(ifapplimble) R 0 2
�• tt. .._._._ . .
PhysicalAddrew Ci mrdti
n �. W.W. P I
10'it �✓!n z1.RFdam
Co ntY Pmrd IdentificatianNo.(MQ t 64!7'W
fib.Latitude and longitude in degrwdininuteslseconds or decimal degrees:
(ifweU field,one latlllongis sa icient) 22,Certification:
rot"N
�1 U4_IU�, w
7
6.Is(are)the well(s) ermanent or 13Temporary Signature of Certified Well Contractor Data
Lay Soft thts farm,I hereby CM&that the weW(S)was(were)CMMCW In accordmnre
7.Is this a repair to an eaisftg weR: �er EPTp ivUh ISANCAC 02C A100 orISANCAC 02C.0200 Well Con uctio:Standards and that a
lfthls Isarepatr fill outAnown well conmuaion Inform don and explafn the nanueofthe copy ofthls record has been providod to die well onmer.
repatrunder#21 rer»arlasedlon oran the backefft farm. 23.Site dinglmmoraddidonai well details
8.For GeoprobeMPT or(3osed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUM ER of wens eonstmetion details. may also attach add'itionat pages if necessary.
drilled-_ t
9.Total well depth below lend aunt ace: 7) 0L) 24a.For Alt Webs: Submit this form within 30
For muldple wells Ust all depths if dl&rm(emwle- Q200'and 2@)1005 cone action to the following � �of completion of well
10.Static water tent below top of easing: 4
(ft.) Division of Water Re`souroea,Inforntatioa Processing IInit,
ljwater level is above oosir:g use^+" 1617 M"Service Center,Raleigh,NC 2,7699-1617
11.Borehole dh�ter. / (ln.) 24b.For ecdon W-Ost In addition to sending the form to the address in 24a
�� above,also submit one copy of this form within 30 days of completion of well
It Well ennstraction method: construction to Ste following
(Le ago rotary,cable directpask eta.)
DIvIslon of WeterBesom ,Undwground]Wecttoa C= of Program,
FOR WATER SUPPLY WMB ONLY 169Mail ser&CeniW,IW@I 6,NC2769NI06
:
13a.Yield%pm) Method of task 24e.Fbr Wa w Sugfy&—lee'rean Welts: in addition to sending the form to
1 the address(es) above also submit one copy of this form worm 30 days of
13b.Disinfeetton type: -1 I� Amount:_1� d�,IrZ completion of MR mnstrut fli to the comfy health depa Covent of the conmy
whefe constrahted.
FormGW-i NorthCarW=Dep wztaMvlroamaatdQuality-Din WonofWawRaw= RwAsed2,22-2016