GW1-2022-07101_Well Construction - GW1_20220801

WELL CONSTRUCTION RECORD LQW-41 For Internal Use Only:
1.Well Contractor Information:
� I.4 14.:WATFR ZONES d
FROM TO I)EKMMON1
Wcll contractor Natne a� ft• 11 t
�16u-
NC Well Contractor Cettificatian Nertnher MOM=CASING(tbrm ild-med WOO OR LINER e
FROM TO I DUNIFTIM THICKNESS I MATERIAL
Company Name 16.INNER CASING OR TOBING( dosed-
2.Well Constratfion Permit f:,S W — 61 i 9 t+rtoxt TO niAMErER TttrCKNUS I MATEPIAL
List all applicable well consitriction permits(ix.UIC.CoWy.State.Variance,etc.) 0 R' ))ti R' ,2 U D Z V
3.Well Use(check well use): R.
I
EN
Water Supply Well: IT'SLBS
FROM TO I DIAMEM I SLOTSIZE I THICKNESS I 1►ternorsr .
Agricultural �M cipaVPublic R. tit. tn.
Geothermal(HeatinglCooling Supply) 63&sidential Water Supply(single) R, R. in.
Industrial/Commerciai DResidential Water Supply(shared) GSOti1T
itr'ration FROST TO bu EarAL n c M%T hWMOD do t
Non-Water Supply Well: 1�-e-
Monitoring Recovery ft. ft. clap
Injection Well: ft. M
Aquifer Recharge E)Groun dwater Rcmediation
19.SAPIDIGRA PACE bte
Aquifer Storage and Recovery j3Safinity Barrier FROM TO I NUTERML I EAn'rAC6aIFdU MEMOD
Aquifer Test E)StormwaterDrainage ft' R•
lrxxperimental Technology 0Subsidemce Control fL R•
Geothermal(Closed Loop) E3Traccr ?A.DRII3dNG LOG attach additional meets if
Geothermal(Heating/CoolingReturn) Othrw lain under d21 RemadLs) FROM TO D WIPTION e¢lar rnMUtoek er�t
o ft. J L1 ft. c t
4.Date Well(s)Completed: 7' 3-ZZ wen w ft o R• Lyl r—
Sa.Well Location;
oand5 + Ann 1 Cilardt rl R. R. AUG
_
racmtytowner Name Facility ID3(if applicable) tiL (L
/��- a 7SJ- & % a.to� rarcoemg UM
i 7 q H�d den Val► Dr I r+�ClO'w' ,r M
Physical Address,City,and Zip d ft. ft.
So1a Q(Y0 Zl.$FMARKS
co n ly Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) Z2.C n:
° 37 ' a,73Jgf" N 6)'55S',?9 35)QS� w a 7— 13- Z�
6.Is(are)the welI(s)04mment or OTemporsary Si Mute ofCenified Well Contractor Date
By signing this fo..I herd c Wfy A.,the-wim xns(►sere)caur.,d in accordance
7.Is this a repair to an existing well: OYes or C�O with 15A NCAC 02C 0100 or 15ANCAC 02C.0200 Wcll Construction Standards and that a
!f this is a repair.fit out totoxtit well construction information and&WWn the nature of the copy of this record has been prorided to the well onner.
repair under B21 remarA:r section or on the back of thisform. 23,Site diagram or additional well detatist
S.IF,or Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only i GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if no essary.
drilled:
9.Total well depth below land surface: (n) 24a,jror All Wells: Submit this form within 30 days of completion of well
For multiple wilts tin►all depths('different(example-3(}00'a//nd 2@100� construction to the following: f
10.Static water level below top of casing: CO (ft) Division of Water Resources,Information Processing Unit,
/f eater level is above caring,
//use"+" 1617 Mail SeMce Center,Raleigh,NC 27699-1617
U.Borehole diameter. t0 Z s� ._._(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Weft construction method: above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger.rotary,cable,direct push,etc.)
Division of Water Resi oes,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service CWer,Raleigh,NC 27699-1636
I
13a.Yield(Rpm) Method of test A CM 24c.For Water Soo*&Infection Welts: In addition to sending the form to
�,,J the address(es) above,also submit one copy of this form within 30 days of
13b.Dfs nfection type: i,h j OY�"-e Amomb 3 1�o completion of well construction to the county health department of the county
where constructed.