GW1-2022-03180_Well Construction - GW1_20220307

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For Internal Use Only:
I.Well Contracmer Information:
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au Contractor Name mDiscagnaN
NC 'Wall CoMICCar Cafti6ation Nanim h It.
dges � / To BiMgCZBR harass MATiittAL
Compeay Name R. G ter.
2.Wen Cotaletdc@on Permit 0: h 616 nw a,,,,
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3.Wan use(check weld are): �, tL y,,
Water Wes:
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Agriculttnal DMunicipaMblic fIG R. !a
(Headng/Cooling Supply) esidwtial Water Supply(single)
m hatiriai/Ca�ial :Residential Water Supply(shared)
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reel un nioM ro MATERIAL
tt�Ac t ra�raoII�rentotrtrr
No.-weary Well: �, C�o n,
Weed"Walk Reccrvey tG tt
monitorift
tr. er.
Remimp DCmundwater Remediation
Aquifer'Stomp and Recovery 0Salinity Barrier gtpat ro P atA i�atAt xi►�t Aced[ ewer Hose
Aquifer Test DStormwater Drainage It. a.
Technology nSubsiderax Control IL _>w
(Closed Loop) DTrecer VIA
lire Re>tum Other lain under#2 i Remarksot►t ° leaser tuudasee,seturadc esys exerts rae
st. w
4.name W0140 C mpieted:t R 2 wen W# ft.
ft Wed Locafta:
Coaj's_��1 ,.. _' m sr.
Facility/Owmr Name Facility DN(if w1 able) tt [6 MAN 0 7 b
Physical Ad*aaa.City,and Zip ft. eti
Az&s L 62 74L?&2yC9.>? 3 -
� `Patoel Identification No.(P"
Sh.Le*mk sad loeattude In degrees/minutes/seconds or decimal degrees:
(ifwall 6eK One bVIM a suftieaa) 2L Certification:
6.Ws m)the wells)&§Permanent or Temporary Sigmunt ofCeruBed well Contractor Datc
By sue$this AM 1 Aereby-n*alert the»e"M rws(wa.)eonatrveted in accordance
7.h tills a rep*to as existing well. [3Yes or No wirA 1 SA NCAC 01C.0100 or 1 SA NCAC 02C.0200!refit Constntctiot Standards and tAar a
If this is a repair,fill oars known wrlf cows mcdon Wamwjwn A.71ain the nah—of the copy of this record has been proven d w the well owner.
rgiab larder#21 mm4a xr im or on the back of rhar form. 23.Site diagram or additional wen details:
S.For Geoprobe/DFT or Closed-Loop Geothermal wells having the some You may use the back of this page to provide additional well site details or wtU
constructiM only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additioasl pages if necessary.
drilled: _ IE SUBMII'PALIlNSTRUCiIONS
9.Toad wall depth below land emrface: (h,)
For makiple wsldo Use oR depths((dower(ewmrple-3 00'and 2Qo 1009 � Far All Wells; Submit this!form within 30 days of completion of well
construction to the following:
10.Static water level below top of au tC: V (1t.) D1vLlon of Water Resources,Inlotm don Prodt,Uni
#'*wet lavel to abort cajL%ere"+
t// / 1617 Mail Service Cemt+er,Rabb,NC 27694-1617
it.Borehole dbundar: _(ln.) 24b.far hdadon Well_■: In addition tW sending the form to the address in 24a
above,also submit one copy of this farm within 30 days of completion of well
12.Well eoastra�n method: construction to the followin
(Lt.wW.roeery,csW dimes push,etc.) g'
Division of Water Resources,Under5mund 14ectlen Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Ce i��ater,Raleigh,NC 2709-1636
13a.Yield(on) Method of test: 24c.For Water Sanely do Inlectiort Weill: 1n addition to sending the form to
the addrass(es) above, also submit one copy of this form within 3o days of
13b.Dbtofeetton type:Jej= Amoaat: completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Camlim Department of Environmental Quality-Division of Waur Resources Revised 2-22-2016