GW1-2022-03794_Well Construction - GW1_20220404

Jan. 29. 2018 10:58AM Env. Health No, 6711 K 1
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p-.WILL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W 1 Cantracto ruro/rm'ono
We1lCdntracnuName FROM TO DFSCRWMN
30oft 30 R.
It. R.
NC Well Contrac or Certification Number :13 OUfEIIGECSL�t(i fdiGinidti<n"5iirweIIs:OR�IlVER` fa'"IiCedte ems.rd o":"
�� �� FROM TO i7 DIAMETER THIMES3 MATERW.
" 1 ft. 7 It �• ,1m ,�.� VC;
Camp ®
r�/� 1e'INNER'.CASINGOICTUniIYCui"'ihirn,dt;cGisedtaa'�•�+rr' ir: tr ti=?r
2,well Construction Permit ll: J Oy FROM TO DIAWMA •TnICIOM" MAURIAL
ustall applicable well rotutnmriohpethdrt(t.e.UIC,Cowry•$rate,Variance,etc.) h h• la
3.well Use(check wen use):
Water Supply 1'Ven, F.IZ°°9CltEiGta:�:t�•_--:.Y ,��.�:,ti�_-�.ti.,.�.;-:�::;�.;,.W_-,�,�:���•-_s==•=== .
FROM I TO ~DiAMI:TfR' SLOTSIZC n � ESS MATERiAL ..
Agricultural Q scspeUPnblic 0 R. Ir. ioJ`
Geothermal(Reating/Ccoling Supply) 01tesidential Water Supply(sing)
_InduatriaVCommerciol OResideatlal Water Supply(shared)
_ltr GOrI FROM I
To N TERIAL E,\lFLACLAIDUMEMOD&AMOUNr
Non-Water Supply Wall rt. It. , ' ' cO t
--- - Monitoring- -- .-- -- Recovery R.- _.. ft..
Injection Well: h. R.
_ Aquifer Rcchargo [Groundwater Remediation .
• 7�SiT,'�IDIGiGY'YEGP.Ye ' Fii...G&ilile'a=_- =.;,.,_:._.�.�•:.:.�,.._ �..a..�,=: .
AquifCr Storage and Recovcry [}Salinity Harrier Taox TO I MATERML EMPLAC><FlENTMLTHOD
_.AquiferTest oStor imiterDrainage m fr.
Experimental Technology aSubsidence Control h•
Geothermal(Closed Loop);, OTMcer s'1aD 1a1G733G.iiaehacal8ohui(dieetritltecaisi' _?--`-•:=�:�=r•-`-=mow
_Geothemedt Heat;nglCool igReturtiL10ther Mloin undertl2l Remarks YROhr I TO DFSCRWFION colar,haTdnuh3al rKk - shr e14
tc.
R. Ct
4.Date Well(s)Completed: 8� aa' well 1D# '15 tG h /'kn . G
5a.well Locations �S iz 0 ll
, nN u_ �.
Timm FIAnna'A
Facility/OtvnerNaam Facility 09(ifi,pplicabt?) n tt 7
a R.
APR
4 1"'CL
Plusicat manes,City,ada Zip L+'netf a cn fix• a pot 0%
Cdudty ParcelMedi6eatioo No.(PIN)
Sh.Latitude and lohgltnde In degreedmiauteslseeonds or decimal degrees.
(ifwell Hold.one ladlongissufficient) 22.Certification:
33.y7S3o3 x- -'8�•a9?41'0 o W U KT W_ bwl � i 3 Ag7 L4C;L
6.18(are)the ivell(s)IOPermanent or [Temporary Sipann ofetnifiedWellContractor I I Dat
By signing ills/orb+.I hereby card r ghat the wfl(s)um?Wre)eommierrd it)accordance
7.Is ibis a repair to Ian existing welt: Q1fea or MCI wish MAN=02C.0100 or IM NCAC 02C.0200 Mill Conrinwien Slaxiaxts and that a
If this is a repair;fig as bloat Well edntr naadh hllcramtion as atplaod the nalrme ofihs copyofthls—,,d hat been prosvdrd robre well osmer.
repairvrrder+� nnmrlrLemonordothebackofdarjbm.
_ -._ 23.Site diaYram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use tho back of this page io provide additional well site details or well
construction,only t GW 1 is needed. Indicate TOTAL.NUMBHR ofwells construction details,You may also attach additional pages if necessary.
drilled 1NSIRUCTLONS"
9.Total iwil-depth below land surfaces �o� O ff6) 249. For All Wells: Submit this form within 30 days of completion of well
Forum lsple>sess ltsteil doptlu ifd:Jferrnr(erarnple.3�00 and i(�100) construction to the following:
� ,
10.Static water level below top of casing: !Sd _—(to Division of Water Resources,Information Vrocesslug Unit,
ljvar+rlevel tr above carws use"+" 1617,Bail Service Cenicr,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24L For Infection Wells: In addition to sending the fann•o the address in 24a
above;also submit one copy of tins fbrm wilt 30 days of completion.of well
12.Well construction method. AO 4 Y,"t construction to the following
(>.r,augcr,rotary•cable,direct pwb.etc.) I 1
Division of Water Resources,Underground Weetion Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Canter,Raleigh,NC 27699-1636
c I ?
13a.Yield(gpm) �+ Method of test: r 24c.For Water Supply&Inleetton Wells: In addition to sending the form to
/� the address(m) above, also submit one copy of this form within 30 days of
13b.Disinfection types �Ar Amount.11 e_(A.Ps completion of well construction 6 tiro county health department of the county
where constructed.
FormGW-1 No#h C=1hmDepnumedt of WaterRcsoar-:es Reviacd2 22-2016:
If :