GW1-2022-03473_Well Construction - GW1_20220323

WELL CONSTRUCTION RECORD(GQV I) For Internal Use Only:
1.Well Contractor Information:
14,WATBR?AN&4 !
Weli Corlwma ame FROM TO DB MEMON
ft. ft< J05
NG Woi1 Cnaha®:Ca1d�6aae��27f
t/► �Q,?z-r W i �• MATERIAL
r UK LRUM Or
FROM TO D1AN� TErnI(�iB96
CompanyNtm�ie-- % •��fL •% h' SQ/�"Z'
16.IlVN13lF CASING OR TUBING dosed-lowl
3.Welt Construction Permit d. d'1 �� /�� FROM TO DIAMEVER I THIC?KKM I MATERIAL
List all applicable wet1 conslntCtionpenndts(i e.UIC,Comity,State,Vwfw ce,etc) & ft. ht.
3.Well Use(check wen use): ft• �-
Water Supply Well: 17.SCRE@N
FROM Tt3 DIAMI SIO�rSrffi MATERIAL
Agricultural �}M pal/Public O tt. & f lc.
Geothermal(Heating/Cooling Supply) �tial Water Supply(single)
Industrlal/Commercid E)Residentlel Water supply(shared) IR GROUT
Khtiaetion FROM I TO MATERUL ENTUCENUMMSMOD&AMOUNIr
Non-WaterSnpp(y well: ' R. 3 r'
PMoaitoting DRecovety FL
Ingecdon well:
Aquifer Recharge [3Gmandwatullamediadon
19 sANID/GBAVBI.PACK(ifinnilhalM
Aquf TStanpandRecovery 133almityBarnier FROM To FUATMUAL------1 EMFLACENI1WMETE0D
1Aquifer Test OStommstaDrainage ft- ff
Experimental Technology ►Subsidence Coimoi
Geothermal(Closed Loop) DTracer 20.DRIIMGLOG attach additional ydazetsif
0cotheanal Coolie Return Other(explain under#21 Remade) FROM TO DESCRiMON color.ttm to sonhad:
% & �
4.Date Wells)C3umpleted: . 94 IDg ft-
7ocation:
cr"J( 1 C'�o�n ft. fe.
Facility/OwnerName Facility M#n(iflicable) ft. &
r
�Ysical Addte�,G4ty,and lip ft. ft.
We 21-RMAM
County ParsxlIdeotificatioallo.(PI13)
6b.Latitude and Iongitude In degrees/minutes/seconds or decimal degrees. '
(tf well field.one lallong is su6icfect)
�0J, 27.( cation:
to S oMertified a etor Daze
6.Ware)the wells) nanent or �Temliorary t�
�� By signing thisfarm,I hereby lotfy that the megs)was(were)oo acted in amvdm ce
7.Is this a repair to an edsting well: E)Yes or De. ivlth ISANCAC 02C 4100 or 15ANCAC 02C A200 Well Construction Standards and that a
I'M Isampalr,fill out kmm well construcdon Injbnaurionm d cWtafn the nurse ofthe copy of this record has bow pwvlded to the mU 4nvaer.
repair under#21 remarks section or on the badk ofthis form. 23.site dingramor additional well deiailx
9.Fw Geoprobe/DPT or Closed-Loop Geotberwal Wells having the saint You may use the back of titis page to provide additional well site details or well
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wtlla eoumetion detaft-You may also attach additional pages Unecessary.
drilled: , SIMNUTTAI.IN3TRUCTIONs
9.Tetal well depth below land surface: UP 241.FOr M Wells: Subnut this form within 30 days of completion of well
For nWdple ivelk W alf depths ifdt#erent(esarnple-3@200'and 2@100) construction to the following: i
10.Static water level below top of casing: (ft.) Division of Water Resource Information ProcessingUnit,
If water level is above eosins,ure"+" 1617 Mail Service Center Raleigh,
NC 27699-1617
11.Borehole dia>aeber. 24b.Far Injection Wellst In sddftion to sending the form to the address in 24a
above,also submit one copy of this fibrin within 30 days of completion of well
12.Well construction nrtlrod:_ conshuction to the following:
(l e.angm rotary,cably diredp-k eft)
Division of VDaberResomres,Undergno>md Rglectton Ce�+o1 Pi+o$eam,
FOR WATER SUPPLY WELIA9 ONLY: 1636Mail St�virce Cenfm,Ralei�L,NC�769A1G3b
13a.Yield(gpm) Method of tesk „ ;*c.For Wooer SuR &Injection WAft- In addition to sending the form to
the address(ea) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �rJCa.-��t�Z_ completion of well construction to the county health denzftmt of the amity
where consmmcted.
Form GW-1 North CaroliaaDepanmmtofEnvrronmtuW Quality-DivWonof WaWR Revised2-n 2016