GW1-2022-03434_Well Construction - GW1_20220318

Jan. 24. 2018 10:58AM Env. Health No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
Coatracto 771'Ibe /`
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Well Contractor Name gaoM TO DFSCRIvrroN
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NC Well ComacorCertifieationNamber (5.01kfEIlG1kS[AiCi lciniditiiised=rve119'ORL ndbli'abl
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OM TO DIANUER TH CIINESS
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2.Welt Construction permit B: 7 FROM I To or lAma TWCKNE69 I MATERIAL
List all applicable well eamriwdon peaAut(l.e.AIC,Caunly.Stare,Yarinnce,etc.) ft. it. In.
3.Well Use(check well ust): n. D. 1n.
i"'Irrigation
sterSapplyl'Ven: mom I r0 DUINETCR LOTSIZE TUM ESS MATERULAgricultural MunicipfiUPublic 0 ft. R.
Geothermal(Reating/Cooling Supply) Residential Water Supply(single) D.InduanieUCommercial Residential Water Supply(shared) 1tAOM TO M TCRIAL Yµi WIFLACEM90.51=01)/4 AMOXWr•
lion-Water Supply Well: Q n. '�$ r►• 'IA
Monitoring r2itecovery R. 4.
I
ection Well: h. o,
quiferRecharge OGtoundwtrter RemediationquifcrStorageandRecovery C)SalinityBarrier I TO MATERIAL EM C bWrHQD
quifcrTest ❑StormweterDrainage R' h'
xperimental Technology CISubside>me Control % R•
eothermal(Closed Laop) E)Trseer s 2QA C•I l aifaeA attd tlo t.vl+eetr[ti+ui4N =r, FlDESCHWHON color,la selYtack siu err.eothermal(Heat;ng/Coolifig'Rettun t]Uter ex lain under Remarks
A Q [tqf ft. _
4.Date Well(s)Completed: b mtT Well ID# �It n' r
Sa.Well Location: Q tL o ft.
bj;Lv a 300 It.
Facility/Owner Name V Facility IDd(if ipplicable) R n'
h n {`
e d R
physical Address,City,sad Zip SGiI�Ct��i N pr$01 _- -
.... ......
Couoty pml:e►Idesdficadoo No.(PIN)
5b.Latitude and longitude In degrets/minutes/seconds or decimal degrees:
(iftt ell field.on tarAong is sufficient) 22 Certification: ( r'* ry
N W ad—ALZ
6.Ia(are)the well(s)OFermanent or [)Temperary 9i8Danae o citified Well Contractor Date
By signing this fore.I hereby cer*rhuir the ireil(t)trot(nemti9)awanvetsd ht accordance
7.is lhls a rtpalr to on existing Weil• [3Yes or.*No with ISANCAC 02C.0100 or 13A NCAC 02C.0200 Well Coarrnrctlon Slar*r&and that a
((this Is a repok Jill as lnotwu well construction frtfarmation WI orplaht the nature of the copy ofthis maid hot bee))pmw,*d to the well owner.
repo$under a21 renmrh zecdan al an the bast of Mtsfarm.
23.Site diagram or additional well details.
8.For Geoprobe/DPT or Closed•Loop Geothermal Wells having the some You may use the back of this page to provide additional usll site details or Nell
construction,only 1 OW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: f SUBMITTAL INSPRIICTIONS
9.Total veil depth below land surface: 300 (n•) 24e. For All Wells: Submit this form within 30 days of completion of well
For mulople wells Art all depthz jdf6renr(emnyld-1@200'and2®100') construction to the following:
10.Slade water level below top of easing: 3 5 (ft.) Division of Water Resources,Information Processing Unit
I/waver level rr above mrvrg toe"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11 Horebole diameter: f .
—_` 4—(In.)
24b.For inleUlon\YeAs: In addition to scndhhg the form 4o the address in 24a
p yr 1 ( above,also submit one copy of this fbim within 30 days of completion of well
12.Well construction method: construction to the following:
(Lm auger,mm*.cable,dueel push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
c
139.Yield(gptn)_ Method „of test: i} A!r 24c.For Water Supply&Inlcetton Wells: In addition to sending the form to
the oddm*es) above, also submit one copy of this form within 30 days of
13b.Disinfection type. tyliff- Amount: 3 LA completion of well construction to the county health department of the county
where constructed.
FormGw-1 NashCaniinaDgadmentofFavitomneetalQuality-DivisianofWaterRcs ium Revised2-22-2016