GW1-2022-05439_Well Construction - GW1_20220607

Jan. 19. JUIU IU:)dAM tnv. Health luo. 0111 r. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.W Contra to Itiformatlo -
c •• anOM TO 10tSCWnTION
Wdl ContrumrName '
YriR c � d
ft. (t.
NC Well Contractor CettificadonWalter `M."Olbx'BACiIS[Pilfi'foitm tii 'hbir
tnaobt To Du Telcicrrss n
17
r lIIVNER.CAShYG?.OR"L�G1Nfr? ..-Ihemidl:Jiis'dd-16' u!m:!�=+�•r•=-��•=...:=<
L Well Construction Perrtut0:, J 0 TO o1 r>ttctovrss xr�ut
Llpa!l applimble xell em:rwe6on pemda#.d.tlfC•Cray;Siard,Yartance.arc.) R rt. to,
3.Well Use(eheekwell use):
WaterSa 1 etL• _ _s.._._.._.._.__. ._.:�.....�:......_. �.__ .� .__•._
Supply TMM ER SL MAMIAL
Agrioult tal Q ic►p ymlic 0 rt. R in:
Geothermal(11-ing/Ceolmg Supply) OMidential Water Supply(sm&) R. rt to
_Industriat/Commcreial [)Resideatial Water Supply(shared) y p �': ._ ". _==s_ •`•. w
I lion NMI T MA RI I M7rrACEM Mt OD&AMOUNT
Non-Water Supply Well: /) R " ' t�
V -•L
metdmring ❑Recovery tt tR
Infection Well: h
_ Aquftitecherge C1Gmundweterilemediation
3XND/GRA. IF EY"6eitile`;;-=F,,w:-�:-:u• "
Aquifer$wrap and Recovery OShcinityBoa* FROM t0 MUTE EMt1A MMOo 4�
_AquiforTest •OStormwaterDrainage R' f
Experimental Teclumlogy Subsidence Control m rt
Geothermai(Closed Lotap),, QTraeer F20-DRIMOI[4Gal�"ai eudlttoAei.liietrffnecio`ai-'•_-' _� := <r_•=.*
_Geothermal(Hearing/CoolirigReturn Other tain under#21 Ramarks ]?Rob[ TO oraCR IOrr alor,bna >otu inrire eu.
S I O fR / tc l�Gr A'
4.Date Well(s)Completed✓ well MN rt• ��•vr t/ {
Sa.Well Locations / h 1, ".'
rf/I 3�sSo7 fL
I A,; h n
FaciliO40a arNadu Facitify IDS(if ippli-bu)
r:.
Ph}sicatAa ,City,aaaTip n ' �9I I UKIF
�.... ..:
C—w Parcel Uen"cmion No.(PIN)
56.Latitude and longitude In degrees nialatestaeconds or dedmal degrees: J
(irmllBald.onetNlangissufficient) 22.Cerfifacation: V a"
6.Ia(are)the wtu(s)l%Permanent or Temporary SQpnn ofetitifiedWellContractor Date
By etgning dds/fomi I hereby eerrt,6•(hat the>,all(k)ism(kem)eatuot tied in aacatdancd
7.is this a repair to an exhdng weM Yes or [3No wh 15ANCAC 02C.0160 or IJA ACW 02C.0200 WeBCommiedon Staadptdt and that a
(Idmlra tapa7.flRmniarous�wdt ean:nuuotrrnfmaarion mud orplam thertaam of the eopyofthts rocdtd troy been prosvdedro the troll owner.
repo order 171 ra cob seeaan or on did baetaflW fore
23.Site diagram or addilioaAi tre0 details:
L For GeoprobtMPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed.Indicate TOTA4 NUMBIM of watts construction details.You may also aaach additional pages if necesmry.
drilled MMMITTAL INSPRIIC YA
9.Total veil deptb below land sorfaee: � 5 (h-) 249. For All Wells Submit(his form within 30 days of completion of wall
Farmufirplcxdlstirs.►Aeprlu construction(a the following
10.Stadc Crater level below top of casing: __(n) Division of Water Resources,Information Processing Unit;,
#Wad?lewt is above Caft we 1617 Mail Service Cehtcrr Raleigh,NC 27699-1617
11.Borehole diameter. (In.) 24b.For Infection Wells: In addition to sending the fort to the address in 24a
above,also submit one copy of this fbim within 30 days of completion of well
12.Well construction method; -0 r construction to the follawmg;
(i.n auger,roury,table,&ut p ik elo.)
Division of Water Resources;Underground Infection Control Program,
FQR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel,Raleigh,NC 27699-106
e
13a.Yield(gptn) ^_Method of test: �. 24c.For Water Supply&tottxtton Wells: Ln addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13&Disinfection type: �!! Amount• Ccof completion of wall constmetion to the county health department of the county
where constructed.
Form GW-1 Nonh Corti mDgm:tmem ofEaviroweaml Quality-Division of Watet Rcsomm Rovisod 2 22 2016'