GW1-2022-06470_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
J.Well ContractorInformation::
`. 0_11(1 i S C4N C/l t � 14.WATER ZDNW
FROM TO IDESOUMON
Well Contractor Name ft-
ft-
yo93 - ,q ft. /46 ft. I 14blIdL-)
NC Well Contractor Certification Number "Is OMM CASiNG'Uoi*-mrittl+ 'Welk'ORLINER`(1re lteeble _
FROM TO DtZed,R TffiCI{NFS& AtATER'AL
At..)D V-1,Lf S h C_ • R. R. in.
Company Name 16.INNER CASING OR TUBING closed-loop) ,
2.Well Construction Permit#: FROM I TO I DIAMETER I TMCKNM MATERUL
list all applicable well construction permits(ie.UiC.Colutty,Sate.Variance,etc.) C> ft' I S$ ft' 1 -29—bL I<DR'Z, l P V G
3.Well Use(check well use): ft, ft. �•
'17.SCREEN
Water Supply Well: FROM TO DUMEM SLOTSEM TERCIWFSS MATERUL
Agricultural Vesideeln7tial
UPublic tt. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) ft, ft, in.
Industrial/Commercial DResidential Water Supply(shared) I GROUT
Itri ation FRO11 TO I A1ATFIU" EMPLICEMW METHOD&AMOUNT
Non-water supply Well: d ft' o?a ft' '_6r" 6'.&
mon _itoring Recovery It• D•
hdection Well: g• (L
Aquifer Recharge Groundwater Renediation
.19.SANDiGRAYELPACK .a Usable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL E!►rPrACFJ1tENT METHOD
Aquifer Test [3Stormwater Drainage R'
Experimental Technology []Subsidence Control ft• ft• j.
Geothermal(Closed Loop) E)Traccr 20.DRD;SdNGI.OG attach addidatud sit"if
Geothermal(Heating/CoolingReturn Other(ex lain under#21 Remarks)) EOM TO DESCRIPTION safersontrarttshz.ete
b ft' 5-'J� ft' rdt*-%
4.Date Weli(s)Completed: 5—'3-a a Well lD# �� ft• a0�ft' rGt.n t -•-
tu. tt. A
5a.Well Location:
034-
Facility/Owner Name
(D 1 �1 Facility IDS(if applicable) D' n' `
.. bf pv1�S .h`1�G ►01, 10"UII� � Zg�l� R. tt. .r+a4q�y'1i�i,� `" S
Physical Address,City,and Zip
:-2.LREMARKC
1A u(1nr�Q �L9 D �I V J Ia-1�Z�OV
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well frbld,one IRNiong is sufficient) 22.Certification:
350 a51 1. 3�" N Sa° iIg-)j&. 22yIf W
6:Is(are)the well(s) rmanent orTemporary ignature ofCenified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or G; Vo W(h 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill aid known welt construction information and explain the nature of the ropy of this recYr l has been provided to the well owner.
repair ander#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprolie/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: SUMAIMUL TNS LMONS
9.Total well depth below land surface: C2 0 5 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3®200'and 2©100) construction to the following:
10.Static water level below top of casing: �� (ft.) Division of Water Resources,Information Processing Unit,
If xvrer level is above casing,icse"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
U.Borehole diameter:to (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of wet]
12.Weil construction method: �O A—o,nn construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Lt Division of Water Resources,Underground Injection Control program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail SaTi i Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: I• Q6M 24c-For Water Suok&Injection Wells: In addition to sending the form to
the addmss(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: CW OY� k. Amount~ Z -Vmlos completion of well consmetion to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Envimnmental Quality-Division of Water Resources Revised 2 22-2016