GW1-2022-06149_Well Construction - GW1_20220623

WELL CONSTRUCTION RECORD For InMW Use ONLY:
This IN can be used far single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
TG-1 `—"A�s t 1 l\ FROM I TO DEsCrdMON
Well Contactor Name `�0 It.
c^
ILlY:
dial Li�C. � �a%
NC Well Contractor Ceriiftcalion Number 15.OMER CASMMG tair'' d0-Vased'%Vdl4 01t,L1NE12 to Itda
FROM TO DIAMETER THICKNESS MATERIAL
I le d k '70 IL 1 f m' 5'- 40 p4 �---
Company Name 16.INNER CASING OR TUBING whatnui etcsed-lob
FROM I TO I DIAMETER I 7111CKNM I MATERIAL
2.Well Construction Permit&3-7'1'3 8 A ft. f4 �
Lfst all applicable wdl permits(f.e.Counry,Stale,Variance,I Jeepon,ale.) ft.
3.Well Use(check welt use): 1I°Se ism
Water SDpptgWtU: FROM TO IAMETER sLOTS17E MUCKNESS MATERIAL
❑Agricultural f OMunicipal/Public 7 ff• l.r�ir. i° •Ufa Set,
c3Gwthcrmu1(HeatineCooli%Supply) 4osidential WaterSuPPY 1 s; ie ff. fw ra
( n6 )
0Inductrial/Commercial DResidential Water Supply(shared) RF 0212T To nutTERtAI. I EMrr ACEM6NT METLOD @AMOUNT
OUri ion 0 ft. fr. O
Non-Water Supply Wellb
mmonitoring OReeovety fL fL
Injection wear
C3AgWfer Recharge OGroundwater Remediation 19.5AAll}IGRAVE[PEf n Ecable
FROM TO MATERGL EWLACEMRNTMEMD
❑Aquifer Storage and Recovery 09alinity Battier g n,
too `�� '"l,6WEL zk-t
CAquifer Test OStannWater Drainage tr.
O13:rperimenlal Technology oSubsidenoe Control
20.'DRILLINGLOG chatTditionalatuetsifnecdfsa
DGeothermal(Closed Loop) oTraccr FROM I To DUSCRWTiON color batdaeagaont b m ' ate
00cothormal Hestia Coolie Retrun ❑Other ex lain under 021 Remarks) ff' ;Z,Q
4.Date Well(s)Completed:5L8L-1�_.Well IDll
Sa.Well Location: d R fG CZ S ,
Facility/Owner Name Facility ID#(ifapplicabk) Q c2` 9
t� C f4 0- ft. Ir fv( 'V � 'Q`'�� -?rl�iU,
f3 $P.l�a�cl-d 'hl`�9 C7;_ C 07 ol-ep `?o too rAl� uc�'4e& pgA S' 4b
Pkalwl Address,City,and Zip � Q 1=0/� I a>�e,vZ�CI ZL RB6fARIGS . s 1 r
FR r<eo�ew�Aa.lc L- s k1 y:
County --- Parcel Identification NO.(PIN) 31
h
Sb.Latitude and Longitude in degreeslminutes/seconds or decimal degrees: 22.Certifieatian:
(ifwell field,one latllong is sufficient) Ini s ; :`?� PrCv^,C'�''3 t;itg Uns,
o. 13 (08 N •--71- . �Q CQ C S W .. '1 - i,c� — " �:�s.Q16OG
Signature of Certified Wall Contractor ato
6.Is(are)the well(s): Permanent or OTemporary By sigrdng this form,1 hereby certj&that rite wells)ivar(mere)comtruetad is accordance
frith ISANCAC 02C.0100 or 15A NCAC 02C.0200 llrell Construction Standards aid that a
7.Is this a repay to an existing well: OYes or to copy of rids record lens been provided to the mall oivner.
this is a repah:full out kaotvn wall omavtruellon Ir'brn Otion aid asplah)die iterate of fhe
mpalr under 021 ren,arkr s don or on the back efiUslorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional wall site details or well
&Number of Wells constructed:. construction details. You may also attach additional pages if necessary.
For multiple lr)ieellon or nomwater supply wells ONLY with the same COMMIc9011,YOU can SUSINIITTAL 1NSTUCTIONS
submit one form).
0.Total well depth below land surface: / (fL) 24a. For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths(fdorent(example-3@200'and 3®100) eonswetion to the following:
to.Static water level below top of casing. /o (ft) Division of'Water Resources,Information Processing Unit,
irwater level Is above casing.urn'•+" 1617 Mail Service Center,Raleigh,NC 2709.1617
11.Borehole diameter, 7 7 (in) 24b.Ea InItAflon Walla ONLY: In addition to sending the form to the address i
24a above, also submit a copy of this form within 30 days of completion of wf
12.Well construction method:,,Yu-U t� construction to the following:
(i.e.auger,rotary,cable,direct push,eto.) Division of Water Resources,Underground Injection Control program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 276"-1636
-� 4 � 24c.For Water Supply&Infection Wells:
13a.Yield(gpm 1't) O Method Of test: "m Also submit one copy of this form within 30 days of completion of
a d�LGt rJ r/1 �Y�CJ fLptZi Tt wall construction to the county health department of the county where
131a Disinfection type: Amount:, a • constructed.
Fona GW-1 North Carolina Department of Environment and Natural Resources-Division of Wator Resources Revised August 2013