GW1-2022-05907_Well Construction - GW1_20220627

Jan. 29. LU I6 IU:SM tnv. Hea m NO. 01 1 1 r. i
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WELL CONSTRUCTION RECORD(qM-1) Fc rIntemol Use Only:
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NC Well Coam e r Certification Number
:(6c0IkTERC3SLtIlfi:fuiTmttIti`"—e3vielG' `slT ltZit6te '�
C� La FROM TO DIM1EUR TEEKWFS9 - MATERIAL
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L Well Construction Permit#: / .-� � FROSt to 0rAtl1ErER 17OCKNM WATERUL
LlrraNapylirabtexellemaunttroapemAu tr.WC Coup,SSme,Variance,etc.) ft. tr. to.
3.Well Use(eheekwell use): n• n tin.
Water Su 1 !'Ye1L• <.12':8t3tEBK:x`T-
PP Y MOU TO D EICR S OTSIZ6 T EO MATERIAL
_Agrlcultuml QMunicWVPublic 0 ft. rc ia•
Geothermal(Heating/CaolingSupply) M tialWataSUPPLY(sm9w)
_IndushieUCommatial esidetuial Water Supply shared --_-- —— -
-Mention FROM 70 btATERlA7. El1PIALTM1tER MEMOD&AMOUNT
Yon-WaterSupp[y Well G r` rr. �' ` , _" rut.
Mortitorimg ©Recovery lt. tit.
InjectionWelL tr.
AquiferRecbarge QGroundwnterRemediation ,-
�s:�silltDrcRalr>3Lrxt
AquiftrStorage and Recovery OSaliaityftrier TMI To MATERIAL EWLACRbtETi bWr11OD
_AquiferTest '})Stanumniter Drainage n R
ExpeiimentolTechnology [—}Subsidence Control 1h IL
Geothermal(Closed Loop), Tracer l0:DRIL•I A`GI33G airne6 audltraltai:sh
FRobt TO DESCAtt?fIOY eolar,ttatdneu,ratYeork ice etc.
_Geothermal(HcatinglemlingRenum Other Lamlaid under#21 Remarks ff n, ft. —lee/C%G{
d.Date Wells)Completed,-2 ///� / Wen M11
5a.Well Location:
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Fap7ity/OwneeName FaeitidrTD1#{itityyticabb) N,:..; r..7 a
Fhy:ical Aa&.k City,coed tip /� i R' `t
County arealIdwifiationNo.(PIN)
5b.Latitude and lahgitude in degrces/midr,tedsetonds or decimal degrees:
(irwall Bold.aaa ladlong is sufficient) 22.Certification: , c7 "
6.Ware)litewell(s)IOPermonent or MTemporary SigunutorterfiffedWeliConnuctor Date
By s pring t/dr fora%1 hereby ea*thar tha trell(f won(kare)tottraticied,71 accordnace
7.Is ibis a repalr to an edsting weer: QYes or MNo with 15ANCAC 02C.0100 or 13A SCAC 02C.0200 Well CoAnnietion Stanctordt and that a
{(this is a repai,fdl as Imroartwdt mattruetiahInformarion mrdaVIO t the nabm ofthe copyofrhts neotd has treenFoilded to eha hell owner.
repnir under 021 mmark recdon orouthd back of ftfotnt.- 23_Site diagram or additional well delalls:-
8,For Geoprobe/DPT or Closed•Loop Geothermal Wells having the same You may user the back of this page to provide additional-.+ell site details or well
construction,only l OW-1 is needed.Indicate TOTA4 NUMBER of 119 - tnteGondetaits.You lady also attach additional pages ifnecessary.
drilled SMNHTTALINSTRU(:TY NS
9.Total well depth below bud surEue- 3 A) 249. Per All Well Submit this foma within 30 days of completion of wolf
FortmgttpleKdts(t:t at/&pda jdpetrnr(emmyle.3@7 'atsiz(a}10G construction to the following:
1D.Static water level below top of casing: t __(tit) Division of Water Resources,Information Processing Unit
lfuawrlot-of fr above ciM&use"+" 1617 Mai[Service Cchter,BAleigh,NC27699-1617
11,Borehole diameter.47(in) 24b.For inlectlon Wells: in addition to sending the fannto the address in 29n
above,also submit one copy of this lbim within 30 days of completion of wall
12.Well construction method: �(.� r ( constmaionto the filloiving:
(%a.auger,w1uy.cable,dime[ptub.eto.) -
DivisionatWater Resources,Ubdergrotmd Injection Control Program,
]FOR WATLR SUPPLY WELLS ONLY: 1636,N&il Servtee Center,Rsleigb,NC 276991636
e.
13L Yield(Elan) 11•Iathod of test*. or ;� l'" 24e.For Water Supply&blectlon Wells: In addition to sending the form to
Ift address(es)above, also submit one copy of this form Within 30 days of.
13b.Disinfection type:—41 Amount: .3 —<<i completion of wall construction ro the comity health department of the county
were annsitucted.
Form GW-1 North tamlmnDepusmew afEm4anweotal Quality-Divisiart of WaterRcraurcer Itevicad 2-22 2016'