GW1-2022-07022_Well Construction - GW1_20220726

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WELL CONSTRUCTION'RECORD(GW 1) For Internet Use only:
J.Well Contractor IuMrmafion:
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G°`e 34 WATER ZONES
WCIIContractarName FROM To DESQIIP770N
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a n.
NC Well Connector Certification Number
M OUTER CASIIIG for adfl ertsai coal OR LiN$B
Etiwtltr>,tn�►WYh>tl ORl1)(AS 4-4- PA-,' �QfVi�(� j FROM . TO . •DUMetr.R MUCKNESS MAI=IA
ft.
Company Name f+
141NNERCASINGORTUBiNG eathet>.al
1-'Well Constiaction Permit#: FROM To DUncarrzR T�cmvss... M&TERUL
List B!l opp(ica6k we((rnnsrntcilpn penniJs!i e.:!/I('.(ourttr,titate,parlance,e1C.1 r b o fc IL Z in—
3-Well Else(cheek well use): ft. 8. is
Lffidjl4naVCommercial
Well: 17.SCREEN. .-
Agricultural FROM TO .. .DIAME7l6R Sr.OT s77Z -78tCS Mwi'ERIAI.
QMur icipal/Public ft.tinal
HeaiinglCooling Supply) DResidential Water Su 1 �D Z
d PP Y
mmercial DResideiitial Water Supply(shared) 13 GR0
. _.. -FROMMATF.RL►h
ETOD&AMOUNTpply Welk
a. --.—_-
_...... Recovery ....--...___._._.. ___.._�__,�}_•
LUeetion Well: 24 ft O a Ciftvl-
Aquifer"Recharge 13Groundwater k6mediation fL
Aquifer Storage and Rei:overy Salmi Barrier 19 6AND1GBi!VEL SACK Ace
ty FROM TO. ttrATERrAL
Aquifer Test Storiiiwater Drainage a ft nor AcBtmvrarereoD
❑ Ho 28 �-�inn@a PaviG
EVerimeritil Technology QSubsidence Control ft : a
Geotlterma!(Closed,Loop) Tracer 20.11RILi1NG LOG albeit atNhiratti sleep if
Gtotlretatal(H oolin Reim)_ n0flw(explain under 021 Remarks) FROM TO DPSCiU! rkM nYr,ian�ea,OWN-t �
ft. ' a;
4;Date Weti(s)Completed: (A•Z• _`ZZ WeII ID#. � rt ry
Sa.Well Location: ft. Ift.
Cxiit +ea OA&Cl- Rfwen 30A 'LLG a
.Facility/Chvar:Name Facility'IDu•{rfepplita6k) ft
1 y 7 Z So Ee bat►Selr► . t4u?o 4 /V G a n
Mysrcal Address,City,an 1d Zip fL' JULJ 21.REMARKg J 29 "J
Comity Sb:Latitude and Parcel Identification llo (PIN) 191�fM�iL+i1 Pry C34
- Un`
lotgitude is degt'ecs/ulitoates/seeouds or decimal degrees:
(dwell field,one lat/lo%is sufeient) -
-,22.Certificatioar
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t%Ls(tirej ilia w �� 7.7.3�Z,z
eil(s) Permaaea't 'or �Temporery srBoenec ofCertrG�Well Contnclar.. Date
7'is thia'a'repair to an existing well: By signing:this John,I hereby certify their the well(s)was,(were)constructed in accordartee
/this is a on inf or "o with 1 SA NCiRC 03C.Q100 or JSA,VCAC 01C.0100 Well Connruction standard;and ihoi a
j repair,Jill out know9r well construction information and explain the nature ojlhA topy''ojflus record has been provided to thr ive!l owner.
repair raider 421 reinarkr seeiion or on the back of this jornr.
•
23.Site diagram or additional well(feuds:6.For Geoprobe/DPT or Closed<Loop Gcbtbermal wells}laving tt a same '
may tse the back of this page to,provide additional wep'site-details of well
oonstivotion,only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if tteoessaty
drilled:_ bNE
9.Total well depth trebw land saitace:
4 SUBMITTALINSIRUCTIOIYS
,Forirru(ttplewelGlisrdtd �' l D •t(a1300'andl(a?100� ( )' 24a. For` AII�grelis; Submit this form within 30 days of.completion of well
°➢m it d+ eren, exnm le-
:construction to the following:
10.Static xater level below tap of casing:
If!,vier.►evel is above casing.use (D-) Division of Water',Resonmes"information Processing Unit,
11.:Bor+elio(e dirtme'ter: (m.)
i 160 Mail Service.Center,Rakigh,NC 276"4617
24h.Fir iuiection Weyer In addition to satding'the form to the sddfess in 24a
12 WeB construction method:_ �-i�R above.,also submit one.copy of this form within 30 days of i�mpietion of well
(i.e.auger,rntaty,eib}et Pub�) construction to tire:following:
=tjP:.
S ONLY: Division of Water'Resourees,Utrd{ergro-d 1o«lion Cosip d program,
16M Mail Service Center,'Raktsh,NC 2709-16M
Methodoftest 21n For Watera
—__-_'e&Inie¢tlorrWelt In addition to semdmg the Conn to
Anmat: theaddress(ei) above, also submit one copy of this foam within 30 days of
i completion of well coristructiori to the county health delrarhnew•of the county
where Constructed.
Form taw-1 North Carolina Department ofEnvitottmemal Quality-Division btWater Resources
Revised 2-22-2016