GW1-2022-05694_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor rm on:
WA#SR70?m I
Well ConbzctorName FROM TO DFSCR<PfION
60
_� n q-� R
NC Well Contactor C on Number 15:OUTER.CASI!!Hs for OR LllNER d
FROM TO DWNETER THX%NE% MATERIAL
G� `� S fL & in. V C
Company Name 16IFIDI$R. <)RTiJBII�I6'
2.Well Construction Permit#: / ) /J E� FROM TO I DIAMETER I TRICIOVM MATERIAL
List all applicable well construction permits(Le.'UIC.Carenry,Store,Variance,etc) ft fl- m-
3.Well Use(check well use): 2 & in.
Water Supply Well: 11 SCREEN
FROM I TO I DIAMETER I SLOTSPLE I TRICKNESS I MATERIAL
Agricultural SM ipal/Pttblic g i
Geothermal(Heating(Cooling Supply) idetitial Water Supply(single) V L
Indusdial/Commercial 011esidential Wat.-Supply(shared) .1R GRt)iFC ..
._ Irrigation FROM I TO MATERIAL EMPIACEM T METHOD&AMOUNT
Non-Water Supply Welk fir G fr.
Monitoring Recovery ft. ft d
Injection Well:
fa fL
Aquifer Recharge DGmundwdter Remediation
19.SANDIGRAeaE1.PitiCg
Aquifer Storage and Recovery 13Salinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test' OStormwater Drainage R
Experimental Technology Subsidence Control fL
Geothermal(Closed Loop) DTM= .L0G—.s+:tKhadditie®1$batig'
Geothermal (Heating/Cooling Return) r30ther( lain under 421 Remarks) FROM 9 DESC3PUF I eoror.hunches,=Wrack ' sme•etc
ft ��
• er
4.Date Weil(s)Completed: - G/ '1.� Well LD# MY /�(�fr- 1 c da•�r
Sa.Well Location: fL L
c ft ft
f
Facility/Owner Name Facility 0#(if le) & fL
/ ` ft fL
/ n-4� L J d er /1
Ply-cal ` Cvy,Vpp & fir
t on' ..21-;REMARES
Cry Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minatra/seconds or decimal degrees: Procc 9 Urli
(ifwell field,one latdong is sufficient) 22-Certification: DWQIB
- W 4
6.Is(are)the well(a) Permanent orr- op"OL.10
rary Sigaatuc of Cercfied Well Contractor Date! / By slgmng this form,1 hereby cerrtfy that the well(s)was(were)constructed in accordance
?.is this a repair to an existing well: with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Welt Consa don Standards and Char a
If this is a nepafr.fill out known well Lnnsnstetton tmformaorion unto explain the nature of the copy ofd-record has been provided to the well owner.
repair under i;21 ra marks section or on the back of thdafomL
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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:
t �� SUBMITTAL INSTRUCTIONS
9.Total well depth
below land surface: 1( ( ) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For mtdnple we&ftaU dtPdu df dfmw(example-3Q200 and 2@100� construction to the following ,
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing
If water level is above casing sae +' rig Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the forrn'to the address in 24a
12.Well construction method: i-y 7�" above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct pu*etc.) construction to the followinrotary,
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test; 24c.For Water Supply&Im Iection Wells: in addition to sending the form to
the address(es) above, also sribmit one copy of this form within 30 days of
13b.Disinfection type: Y7',f Amount: 0-It- completion of well construction to the county health department of the county
where constructed.
Form GW-1 Notch Carolina
DeparTmenr of Fn-ronment al Qabry-Division of Water Resources Revised 2-22-2016