GW1-2022-06827_Well Construction - GW1_20220715

W__ELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I
I.Wall Contractor Ldormation:
Mahn14,'WATEI- ZONES
Well ContaktorName FROM. TO DESCRWHON
ft. ft. Z
NC Well Contractor Certificadon ft. ft.
er
15.OUTER CASiNt3 far multi cased V4 OR LINER e
Ira � � �� FROM To Dunn,raR TIOCKRUS MATERIAL
p fY. % In.
company Name � (�
.P &1 t - ' ?3'q 7G IIVNER CA G t)R'rIJH is msl closed-!
2.WeII Construction Permit#:L� , FIRMTo DIAM1fETER TarcttrtFss n1nzF.RtAL
List all Whkable•well construction permits(i.e. IU C,'Count): te,& Varian eta) a. ft. in.
3.Well Use(check weR use): ft I ft. to
Water Supply Welh i9.SCRLEN
FROM TO DIAMETER SLOT Sr2W; TffiCKNMBS MATERIAL Agricuhural MunicipaU4'uhlic ft it In.
Geothermal(Heating/Cooling Supply) dResidenthaWater Supply(single) In.
In dusttial/Commercial E3Rcsidential Water Supply(shared) i8. O1DT
Imi tion FROM TO MATERIAL EMPLACEMENT MET9oD&AM1101AYT
Non--Water Supply Well: ft.
Monitoring Recovery ff. ft.
ectlon W
AquiferRecharge QGroundwaterRemediation ft. ft.
mufer Storage and Recovery i9 SANb/GRAItEL SACK [ cable
�l g �' �SalwityBatrieC FROM TO tNATERiAL LACEMENTMETROD
Aquifer Test 0Stotmwater Drainage ft. %
Experimental Technology Subsidence Control
.:.:
Geothermal(Closed Loop) DTnteer
?A.DRII,LING.LOG.etfaeh addttPoiial'8lieev ltnecels .:_.;.;,.
Geotbermal ggt;m Conlin Rehm) Other lainutmder#21 Remarks) FROM TOI DESCR/VrM eo[or[n "i6iUracmc 40 IL
4.Date Well(s)Completed: L Well ID# v tL 'Soo & YQ vt 0 4 S
Sa.Well Location: t ft. ft..
.T�r4i1� rD ft. ft
Facility owmxr Name
Foci' ID#(if applicable) ft R,
I., V rR
Physical Address,City,and zip n• n• J U L 202?
rah O9 40OLO7374 22.RE11lARIfS
County Parcel Idendftcation No.M j.
56.Latitude and longitude in degrees/miauteslseconds or decimal degrees;
VVIIIA1,61A,luI'll rR J.:L z—.N,l9 JI
(ifwell field,one latllong is sufficient) i
BB.Certification:
N W
6.10(are)the wells) Permanent or Temporary il'�� Certified Well Contractor �° Date
Bp sign!g this form,l hereby certify duit the stwlt(s)was(Here)eanstntcted in accordance
7.Is this a repair to an existing weR: •E)Yes or No with 15A NCAC 02C'.0100 or 15A NCAC 02C.0100 Well Constntatlon SYandands and that a
J ibis is a repair,fill out lotomort Hell construction In and explain the nature of the spy of this record has been provided to the all owner.
rgjairnnder 021 remarks section or on the back of thisfonn.
23.Site diagram or additional well details:
You may use the back of thus page to.provide additional well site details or well
8.For Geoprnbe/DPT or Closed-Y oop Geothermal Webs having the same
construction,only 1 GW 1 is needed. Indicate TOTAL NUM3ER of wells construction details. You may also attach additional pages if necessary.
( SUh3MITT'AL INSTRUCTIONS j
9.Total well depth below land surface: 500 _(f�)
For mult(ple wells list all depths Jf d!j/erent(example-3Q200'attd 2@100) 24a.F°r, All`Wens: Submit this fatm within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 20_ (ft)/fxwter level is above casbt&use Division of Water Resources,Information Processing Unit,
"+" 1617 Mail Service Center,Raleigh,NC 27699-16I7
11.Borehole diameter: (in.) Bob,F°r Iniectton Wells: in additsoa to sending the form to the address in 24a
12.Wen construction method,�( ,L ab0�+ submit one copy of this form within 30 days of completion of well
(to.auger,rotary,cable,direct push,etc.) construction to the following:
rFFOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground IDJection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
I' '
.Yield(gpm) Method of test: 24e.For Water Sunnly A inlecdon Wells: In addition to sending the form to
the address(es)'above, also submit'one copy of this form within 30 days of
.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Fort aw-1 North Carolina Dwartment of EnvironmentAm n.,-uti.-n;,a.: