GW1-2022-03028_Well Construction - GW1_20220228

%VFI L CONSTRUCTION RECORD(GNV-1) Forinterna Use Only:
1.W II Contractor Information:
�- JWA'T1 TO DLccRPTION I
Wen Cntraetor N m n.FL
NC Well Conmactor Certification NumberARING fer ma(tttnd welt'OTO DIAMR'MRT111CK9LSS MATERIAL
Cascade Drilling. LP �ConvanyName ASINGORTUBING IbentnItTO DIAMLI7A i -nuckVLSS - MATERIAL
2.Well Construction Permit#: rra�() R a Ia -Y lint a0 applicable Felt coarn,cilon permiu(Le.U1C County,Store,Variance.etc.) ail R -
3.Well Use(check well use):
n scaIEEN
Water Supply Well: FROM To DIAMER•R sLorerase TIOCIcvrss MATERIAL
❑Agtieultural ❑Municipal/Publie G R R a to ,On 56.11 q0 PVG
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Is. n la
❑Industrial/Commereial ❑Residential Water Supply(shared) ILGROtrr
❑Uri ation 0Wells>100,000 GPD FROM TO MATTiUAL tN rIwCLNCR METNOD�AMOItYT
Non-Water Supply Well: I S (L 17./R 10 e z N 0 v i-
- lrlafenllOrin - ❑Rao Q IL
IS R 0(.. Gt'13' '`(iW►f+^ �i —
Injection 1: rL R
❑Aquifer Recharge ❑GmundwaterRemcdiation if.OANDIGRAVLLPACK f■ bit
❑Aquifer Storage and RccowAy ❑Salinity Barrier FROM TO MATERI LNFLACEMLVTME7NOD
❑Aquifer Test ❑Smrmwater Drainage P- n- 3t7 R I q 5 QOIA t'
❑ExperimmtalTechnology ❑Subsidence Control R R
i
❑Geothermal(Closed Loop) ❑Tracer 20.OR1LLING I OG artier Dal ahseo u
FROM I To DLWRIrnOV "W soda undnek N+ve.err-
❑Geothermal(Hratin oolin Return) ❑Other(explain under#21?Remarks) l n
4.Date Well(s)Completed: OA"10- Well rD# '✓ n Ilo R
1 R I R
So.Well Location: 3 l) D
R R
Pfizer '
Faci6 IDk des R It. .
Fseilicy/pwvcName dY ( PPlivable)
R R
4285 N.Wesleyan Blvd Rocky Mount NC 27804 R R
"ical Addeesa.City.and zip ProUnk
xl:REINARK3,
Nash
County Panel Identification No.(PIN)'
5b.Latitude and longitude In degrees/minutea/seconds or decimal degrees:
('dwell field,one ladlong is sufficient) 22.Certification:
N W 0 -to-d.1
Signature of Certified Well Counselor Date
6.Is(are)tht wcll(s): Xpermaoent or ❑Temporary
By signing thLi form•I hereby ratify that she walls)was(rani cave+rted in accordance%*A
7.Is this a repair to an existing well: 0Yes or A10 ISA NGC 02C.0100 or 1fA NCAC 02C.0100 FI e11 Cauovrrim SaAdardr and slot a ropy
If"it a repot.,ftB owl byre%yu eonetmetlon information and explain the nature of tht of thb record heir[eee provided to the reU owner.
rrgao undo 821 rtararks atcuon or on the back of this form. - 23.Site diagram or additional well d!W ts:_.. .,
You may use the back of this page to provide additional well construction into
S.For Geoprotx/DPT or Closed-Loop Geothermal Wells having the some
(ndd'Sa Over in Remarks Box).You may also attach additional pages if
coostrut�ion,only I G W-I is needed. Indicate TOTAL NUMBER orwells
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (n•) Submit this GW-1 within 30 days of well completion per the following:
for mwlt(plt rrlb lit all depts(Idif lerew(exafflIde-)(0200-and 2@1007
24a. For All Wells: Original form to Divisionof Water Resources (DwR)
10,Stacie water level below rap of cooing: Ys' (n) Information Procasing Unit,1617 MSC,Raleigh,NC 27699-1617
If%ater kcal it abmw cmiaL use
11.Borehole diameter. (Ira,) 24b,For Inlection Weill;Copy to DWl(,Underground Injection Control(IUC)
G Program,1636 MSC,Raleigh,NC 27699.1636
12.Well construction method: 24e.For Water Sup I glyand0pen-LoopGoothermd Return Wells:Copy to the
(i.e.augn,rosary,cable.direct pus4 cu.) county environmental eputment 01 toe county wocre InS
FOR WATER SUPPLY WELLS ONLY: 24d or Weser Weller roduelo over 100,0 GPD:Copy to DWR.CCPCUA
Perrin Pmgr4m, 61 I MSC,Ra el , 'C 27699-1611
13a.Yield(gpm) Method of tat: f
13b.Disinfection type: Amount:
Form GW-I Nmlb C4ru4ma Department of Eaviturmccul Quality-Divi&wn of W=Rtsmrcea Revised 6 -201 g
l .
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