GW1-2022-02993_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(GW 1) ForintemdUse Outy:
I.WAH Contractor Information:
14.WAT1gR ZONn
Well ComactorName FROM I TO DBSCR MON
,�,/�/��� toe �• I�y�•
ft.
NC Wets Contremor Ceeti62i
rweft
F$OM 11 TO D ��IIf�nN�B MA'f1111;m
CompanyNama I,I 1R• .J9W-0q6
16 INNBRCASING ORT BM elosedd
2.Well Construction Permit* FROM TO DrAMEM THICKNESSMATt;atAr.
List all applicable well caastntedonpvwdts(le.UIC,Comas,State,l wfoce,elm) R•
3.Well Use(checkweil use): fL ft. In.
Water Supply Well: 17.SC IMN
MOM TO DUMP tM SU TBRUt
Agricultural j3Mum " lio 0 ft. f f hu
kGeothermal(Heating/Cooling Supply) 'dermal Water Supply(single)
1ndustrial/Commercial EIResfdentiai Water Supply(shared) X GR013T
ri lion FROM TO MATERIAL EiV)pt.AC�NT oa&AMOUNT
Non•WaterSupply Well: ft-
Monitoring tt• fL
Fgiection well:
laeotherund
quifer Recharge DGrouudwehxRamediation
19 f1AI+ID/GRAVBi,PACK N f'lteobl
quifer Stomp and Recovery OSalinityBarrier FROM TO MATEUAL EMFLC8I1ti�Pr OD
quifer Test OStomiwaterDminage ft. ft
xperimental Technology DsubsidenceComml fb ft.eothenrW(ClosedLoop) E3Tmc;er 20.D GLOG atiachadditionaldeefsif Conlin Return Other Iain under#21 Remadcs) FROM To atasexnrriox ewer tuudn aoahodc
ft. &
4.Date Well(s)(bU@lefed:�„�L1 Well ID# ft.
Se.Well Locution:
Facility/OwnerName Facility M9(if applicable) % ft. MAR 0
(� �33 ft.
r-"!
Physical Address.City,and lip ft. ft.
21.11EKARRKS
County Parcel IdeotificatimNo.(PM � C I�� Irlpr
3b.Latitude and Iongitude in degrees/mhrntes/seconds or decimal degrees:
of well field.ape latilong fa anmcfe ) 22,Certification:
P12 Y6ey-PN Zg�63-(sl �&/zi 2 6-6" w 0��'
6.Is(are)the wells) arm ment or DTemporm7 signature ofCeefiSed Well Contractor Date
By signing this form,I hereby anify that the wells)was(wm)canstrucled in naoidanae
7.Is this a repair to an existing well: My'-","or ONO with ISANCAC 02C.0100 or IJANCAC 02C.02W Well Construction Standards and that a
If this is areparn plout kmm wail construction information and explain the nwureofthe copy of this necordhasbeen prudded to the well mvncr,
repalrunder#21 remark rudion aron the bad ofthis form. I .
23.Site diagromor addifional well detdLv.
8.For GeoprnbelDPT 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 i E 1 is needed. Indicate TOTALNUMBER ofwells constructiondeteils..Yon may also attach am"pages Nuccossa y.
drifted:
9.Total well depth below land surface: ( ) 248.For All Webs: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ffivent(elm wle-3@200n0 and 2@I00) constnmtion to the following:
10.Static water level below bop of casing: r�-� (ft.) Division of Water Resources,Information Processing Unit,
1f wmer level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
lI.Borehole diameter: 24b.Fbr Infection Wells: In addition to gentling the form to the address in 24a
12.Well construction method: above,also submit one copy of,ft form within 30 days of completion of well
(Le auger rotary,cabk d;Rctrnst,etc-)
conslnrction to Ste following
Division of WaberResoarees,Undelglou a bdection Cmnlr+ol Program,
FOR WATER StFPPLY OPILY: I63dMai1$eivic�Cenf�er,Re(eiSh,NC2"j6yg,.1636
13a.Yield(gem) Method Of teM 24c.For H1510C&Mk&Inleam Wellp In addition to sending the farm to
the addtess(ec) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount 6, completion of well cost ctioa to the oo.W health department of the contm,
where constmebul
F0m1GW-1 NorthCaroUnaDepeama tofEwArenmentalQuality-DiddgnofWatm'Resomm
Ravised2-22-2016