GW1-2022-03472_Well Construction - GW1_20220323

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WELL CONSTRUCTION RECORD QW-1) For Internal Use Only:
1.Well Contractor Information:
2n 0d% 14.WATER ZONES
Well ContractorName / l FROM TO D$SCRIPTION
xc WA can c�sen, N,>� l 8. t)
r worn-cases we R LIPtBR iicaDte
FROM TO DIAMSTSR THICKNESS MATl,ERUL
4 in. SD - l/
Company Name I
16,DNER C49M OR TUB G dosed400
2.Wen Construction Permit#.- VVV��V FROM TO I DUMEM I TMCiCNESS I MATERIAL
Fist all applicable well construction permits(i e.UIC,Comb;,,State,Parlance,ele.) ft. R• in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17i 9CRSEN
FROMTO DUMWER S= MOCSNBSS MATERIAL
Agricultural DM ctpal/Public p ft. ft.
Geothermal(HeatingiCooting Supply) &Qdential Water Supply(single) &
- Industrial/Commercial DResidential water supply(shared) 1&GROUT
FlInization FROM TO MATHIUAL EMPLACEMENT OD&AMOUNT
_
Non-Water Supply Well: ft- ft- t'
Monitoring Recatray ft. M
Infection Well:
locothermalMe"
quifer Recharge ElGroundwater Remediation ft.
19:SAND/GRAVEL PACK f ileabie
quifer Storage and Recovery Salinity Barrier FROM TO MATER AL EMPLACEMENT METHOD
quifer Test OStormwater-Drainage ft. ft.
xperimental Technology Subsidence Control Yw ft.
eothermal(Closed Loop) �Tracea 20.DRILLIlVG LOG attaeb additional shots if
in Coolie Return Other lain under#21 Remarks FROM TO DESCdtRnGN color soutmac
ft. ft.
4.Date Wells)CDU@Ieted:_-2-2 '2 ll IDi!
So.Wen Location: ft'
~Faciiliittyr/O,mer Name Facie W#(if applicable)
FL ft. MAR 2 _
Physiiod Address.City,and Zip ft. R'
vl•�a��l�L` �'� 2t.REnZAFM
County Pmtxl Identification No.(PIN)
6b.Latitude and longitude in degrees/minutes/seconds or deelmal degrees:
(if well field,one lat/long is sufficient) 22.Ce cation•
.Zyl�r�g N '7 - ��� � � w oz
2 7
6.Nam)the well(s) rtnaneat or Temporary alga cettised�✓� r Hare
By signing this farm,1 hereby cmtfy that the wells)was(were)cmrsbacted in accordance
7.Is this a repair to an existing well: E3Yes or 090 with 15A NCAC 02C.0100 or 15A NCAC 01C A200 Well Construction Standards and that a
ftthis is a repair,Jilt out well consnucdan Information andexplaln the nature of the ropy of this record has been provided to the wil owner...
repair under#21 remark section or on the back of#&form. 23.Site diagram or additional well details:
8.For GeoprobelDPT 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details-You may also attach additional pages if necessary.
drilled: 91 M= r=INSTRIIGT10Ne
9.Total well depth below land surface: 24a.For All Webs: Submit this form within 30 days of completion of well
For multiple welts list all depths ifdi$errnr(emmple-3 a()200'andi 1001 construction to the following:
10.Static water level below top of casing:
1f water level is above casing, ft) Division of Water Resources,Information Processing Unit,
"+" �g ?''
g 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.iigr Itueetion WeDss In addition to sending the form to the address in 24a-
above,also submit one copy of this foam within 30 days of completion of well
12i.Well construction method. � � � construction to the fallowing:
(Le augey rotary,cable,duea push,etc.)
FUR WATER SUPPLY WELLS ONLY: Dsion of Water Resources,Underemand 1 eeflon Control Program,
A 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.17eid(gpm) Method of t [-1c.liar Water Sourly&Inlection Welts: In addition to sending the form to
the address(es) above, also submit one copy of this four within 30 days of
13b.Disinfection type: Amoi36x completion of well construction to the county health department of the county
where constructed_
Font OW-1 North Carolina Depaimtent of Eavimonmentat Quality-Dnwwn of Water Resources Revised 2 22 2016