GW1-2022-06713_Well Construction - GW1_20220712

Jan. 29. 2018 10-:58AM Env. Health . —No. 6711 P. 1 '
WELL CONSTRUCTION REC01W aW-1) For Intemal Use Only:
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-e 6 BAOM TO DFSCREPTION
WeneontractarName
NC Well Coaaacor Certification Number. 13.OUTERCaSING! irmTdkiciiie�='elia'OItL
�I�YII S l t�(' [ PROM To DIAMETER, TH[CKNPS9 MATERIAL
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2.Well Construction permit#: rROMI To OtAM>vfER TRICIINESB MATERIAL
Lfstall applicable well h mutrnetioa perahhs(1.e.t1IC,Counly, ore•Variance,ere.) n• h. J In,
3.Well Use(cbecknell use): n. It. tn.
Water Supply Well- �12:SLRE$hLF`T:�=-�^�=�=���:_��.�•.�'�:�:�.^.���ii-��._�?,'�^
FROM I TO I DIAMErEa. ,SLOT SIZE TLL[CtrNFSS MATERIAL
_Agricultural C)Mnnic psypublic
Creadtermal(HratinglCooling Supply) idential Water Supply(single) n, h in;
_Indushriat(Commceeial E)Resideatial Water Supply(shared) *atQxOliT;=== ^"• -^e °=='= z - � °
_Irri ti0n FROM TO MATERIAL EMMPLACEME TFME11101)$AalOUNr
Noa-Water Supply Woll: , ' �N
Monitoring-- -- ' ... ❑Recovery
Injecton Well:
h fr. .
- AquifcfRecharge, 0(;mundwaterRemediation _.
LAquifer Storage and Recovery C)Salinily Barrier FR05l TO MATERIAL EMPLACRMEt�n'MCI'ROD
Test E)Stormwaler Drainage &imental Technology Subsidence Control n,ermal(Closed Loop) 13Tmeer :='l0_Tl • �•L0G eii&"el:addltlotuiul FO&TtrecFROM TO DfSCRIYIION olor,berdneu,sollimtk lime etc.ermal(Reating/CooliegRemm Other ex loinunder#21Remarks G tr. / ft. IE G!a y
a.Date Well(s)Completed:. Well IO# CIWI e 12_"
Ea.Well Lnaatiout 1,2 S n
illcilitffOmef Name FaeilitylDJI(if opplicable)
floral .I".�ru/ Lf/a "'VC
It. m Zti.
Phys� 'y,add Zip rim FL ,
fv rxm(ijA NOGESSEM Ui1f
Couay parcel Idenitteatiaa No.(FIN)
Sh.Latitude and longitude in dcgreeslmiautes/ieconds or decimal degrees: / ^`
(irYvell field,one ladtong is sufficient) 22:Certification: V � d-
3S0 r) 3 72/0 N FI CV ' d 7.3 cw
6.Ware)the well(s)OPermenent or QTemporaey 3ig<lanneo errifiedWellCanaactor Dale
By signing this form unr(were)comovered hi occoWbace
7.Tim this It repair to an existing wet Yes or ONo with 1Sd NC,YC 02C.0100 or 19A NGIC 02C.0200 Well Connnrcrlon Slatxfatetr and that a
((this is regal,Jill otn mown well caurruvion ejarmarim and eoplant the naNPe ojthe copyofrhli record has been pror7ded to the wellowrter,
repairunders7l reamrls sectionbran the boekofftfomL
23.Site diagram or additional well dclalls:
8.For GeoprolleMPT or Closed-Loop Geothermal Wells having the some You may ueo the back-of Ihis page to provide additional urll site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL,NUMBBR of wells construction details.You may also attach additional pages if necessary.
drilled: SUBMIT 'AL INSI'RU(;TION$
9.Tolid well depth below land surface: t'/s (RM) 24a,For All Wells: Submit this form widiin 30 days of completion of well
Formiduplam►Is(trra►ldrpt6ildifflienr(crumple-3(dj200•and2gl0&) construction to thefollawing:
10.Slade water level below top of casing: (ft) DWalon of Water Resources.Informatlon Proeesstug Unit
ljwmer►evel u above eases&t1te+" 1617 aaVail Service Center,Raleigh,NC 2709-1617
IL Borehole diameter: (In.) 24b,For inlecllan Wells: In addition to sendntg the iannto the address in 24A
12.Well construction method: P-0`(Ot.N 1 above,also submit one copy of this'fbmr within 30 days of completion of Iwvoll
construction to the following:
(i4 auger,rotary,cable,ditrel pmb,CIO.)
Division of Water RcYodrees,Underground Injection Control Program,
BOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(aptn) v Method of test: 2de.For Water SunOty 8r Inlectlon Wells: In addition to sending the Conn to
✓ the adtimss(es) above, also subtnit one copy of this form within 30 days of
13b,Disinfection type: Amount: a ��f completion of well construction to iho coturty health dcpartment of the county
where consiructed.
FotmGW-1 North Caml'mnDepanmeaf otEoviramneanlQuaBy-Division ofWatcrRcs— Revised2-22-2016'
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