GW1-2022-03438_Well Construction - GW1_20220318

Jan- 29. 2018 10:58AM Env. Health No. 6111 P. 1
WELL CONSTRUCTION RECORD LqW 11 For Internal Use Only:
1.W 1 Cottraeta Iatormatio
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NC Well Coaasc of Cettifimaiion Number
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2.Well Construction Permit tk oM TO sir THt�IQtEB$ M;�
/.lsl all applimb/e well ZmnrtrnCriohperMfrt R.e.W.Coronary,Sure,Yarionae,em.J- It.
3.Well Use(cbeehwell use): rt h. to
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Well: OMIlnicipallMliC SI7E Tt[CKNPSS MAhTJtTAL
Qmtitmg/Cooling Supply) ddentiat Water Supply(single)
taseial ft.eatial Water Supply(shomd)
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njectimaidon l: ORecavery it n:
echa►go OGmundwater Remediation lY. ft
torage and ltecavery OSalinity H6arier 1�iYND/GRii3Bls1',1 Eli"` fable _--A=.;_.�;.rsti. .
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est [)StommmlerDrainagetal Technology OSubsidenceControl Rl(ClosmxiLoop) OTnwrl(Reating/CooJingRenan Other lainunderi?21Rematks FROM TO DID t tor,tf seive,ticy� u�
4.Date Weli(s)Completed: d1 Wen IN O R 'Q0 n
5a.Well Locanout 1010 IL 1-196 1
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Racm7itylOwner Nama Facility max(If iolicabb) Isle
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Couad PurAl.Uen"cation No.(PIN)
Sh.Latitude and lotreimde in degreeshoinuhysewads or dedmal degrees;
(ifwe11 Md.one tadlmmgiasufficient) 22.Certtfieafiaa:
N Wa 6.la(are)the well(s)OPermanent or OTemporary aqpUffure o9cculned Well Cantracror Daro
By aipring rh r f&ft l he*eve that the mrego um Mmmr)ta1mmIld t oaordoace 7.U this a repair to aD existing well• Oyes or �110 with Ild AW 02C.0100 sir UA NGIC 02C.0200 Well Conrrnauon Smnevy&and Oat a llftisamrpalr,j1Bo,nhwmwmwdicenntmwanlnforawriam f=thenahasoftbe mpYofWs.aamdhatbeenporrdrdtotherrdlowner.
.eparr under 021 remaris+colon bran the had gift fora,
23.Site diagram or additional well Maus:
&For Geoprobe)DPT or Closed-Loop Geothermal Wells having the some You may use the back of Ibis page to provide additional well site details or well
construction,only I GW-1 is needed.Indicato TOTAL.NUMBER of was construction details.You may also attach additional paps if necessamp.
drilled:
Q0 �TALINSTR CTIONS
9.Total well depttm below 11jg4U Ind surface: o (h•) 34a. For All Welts: Submit tbis'fotm within 30 days of
FOP mtminplexetk&rtaQdeprJ,.,Jd<petr„r(eanple.3�70p•aad2�I00� 9 completion of well
Oconstruction to the following:
10.Statle~valet level below top of casing; (ft.) DIVWMI of Water Resources,Information Processing Unit,
ljwareriavaluabmrembrgure+" 1617'Vail 8erviceCeDhrrltalelgh,NC27699-1617
IL Borehole diameter—�--'(�,)
24L For iniec�lon Wens: In addition to 3cndiag the fmmto the address in 24a
12.Wes construclion method:_- /` Y, above,ego submit one copy of this fomt Witlnt 30 days of completion of well
CLe,ago.rolamy.cable•daect push,No.) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground lnjeedon Central Program;
1636\Vail Service Centric,Raleigh,NC 27699-1636
130.Yield($ptrm) Efethod of test: Zoe.For Wafer Sunahi Br 10 ectloa Wells: In addition to sending the form to
1 we address(es)above, also submit lone copy of this form within 30 days of
13L Disinfection type: �r Amount: 3 G� completion of well construction to tho couuy tmcaith department of the county
where constructed.
FormGW-1 North CemrumaDapazmmeat afFavimoomeand QmNw-Division of Wow Remoamces '
Revised Z 22-2016-