GW1-2022-07138_Well Construction - GW1_20220804

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WELL CONSTRUCTION RECORD EW 1) For IntemslUseOnly. I
1.WenContratdorInformatton:
�w�'►A (044ce\ Z(HE
Nall CwhetorName FROM TO D13SCR1PTION
3oa y A I sit: 13
NC WallCoa4ma�rr,;a�an?- � � p � '
- .. Wrr Or
Q�lS W i ZC►C2�S /)C FROM TO DT BR TAICSNB3B MATIJRiAL
CompanyNFamo Q t� Sa--At. & t iD. SD .ot
16.MOMCAWGOP.TMWG ih�aleiosedd
L Wen CensftwAon Permit•#: P-3(off O I 11 PVC,
y FROM To DrAMCT T>uc ss IMlAT>;Riat:
Llsr all applicablewe�l constructionpemats(l e.UJC,Coup.State,Yivimue,era) ft. tl: im
3:Well Use(cbecgwell no): ft. ;• iD.
Water supply�PeII: 17.5CREErL
Agricultural 13Mlmicipambno, pOMfr~ ft fa. stomata ltaeTantAt
Geothermal.(Heatingcoofing Supply) dential WOW Supply(single)
ustrlal/Commerciei DResidendal Water Supply(sbared) 18:G7RODT
ltri fluor MON I TO &AMOUNY
Non WaterSupp[y Wam it. ft-
_JoRewvw
bdeetion Well:
. AquiferRaduu a DftwldwaW' Remediadon
Aquifer 39.SAAIDIGRAVBLP CK leJ ;
_ AQ t17r8S0ffiIQI�GLOVety �SHIIl1IC}rDAlliCr FROM TO ZUTMMLBMPLACPp D
Aquifer Test DStom waterDreinege M
Expedm3uld Technolou DSubsidedca Control ft; ft
Geothermal(Closed Loop) DTracer. 24.DRD.FdT•IGLOG attaehadditiondstmeba
a Geothermal eafingjCoolingRetnm O@ter a ]aiaimder 2lRemadss) FROM To assaalrTtoN eclorhmdn solVioek etc.
4.Date Well(sj Congdefed; WeII IDP G4 S ID V
5a.WelFLoeaidon:. NT7ft.
VO
_Lee.
facWty/OwnerName Faeiiitym#Crapplicable) ft.
/n/ IL ft. s
?S36 &O S ke^ Q G) %) j� n n c-�Y" r
PhysiedAddres.ft.m► Zip Z-7 (o�' % M AUG 0 R 2022
21.REMAM ;
CoUW
P�xtidentificationNo(PII� i' Infocfl-iatiert PIo;3s
6b.Latitude an4 longitude in degrees/minutes/seconds or decim d degrees: 1
(ifweli field,one latllongis su6'ielent) 22.Ce ' cal : 1
3�. 738111 W
L(are)the well(s) ermanent or Temporary orcertire WencojudKr Date
� BY slgaing tlAs fatn►.I herebJT�tjfy thatlhe»r11(a)ivar(tivere)cmurructed in accordance
.7.Is this a repairtoaD UdStiagwell: E37es or o ividt 15ANCAC 02C.0100 orISANCAC 02C.4200 Wag Consrr WftSwndards imildwa
lftisareFfibVlloutknormwelianaaacdvninjbn=1oa and aplaladwndtureaf fix. -pyqftWsrzcurdh=hanpwWedjaftwaoj7ner.
repab under#21 remarkssedtoaarontbebackofthfsform: 13-Sitedlegremoradditionaweudetaila
8-For Ceopr-heMPT or Qosed-Loop Geotherus dWeRs having thesame YOU may 11se tlse back of this page to provide additional well site details or well
construction,only 1 GRl-1 is neede(L Indicate TOTALN[]MBER of-was constntctioa details_.Yon may also attach additional pages ifnece myI. '
drilled: MMMnTAT DISTRUCMNS
9-Total well depth below land surface: T!!O (ft.) 24E6 For Ali Wells: Submit•this fora within 30 days of completion of well
Formutdpleivelts&taffdepthsydfperent(example-3@200.'mtd2@100) _ constracaloatolhefollowing!"
10.Statiawater level below top of casingsDivision of Water Resonrces,InforDistioa Processing Unit,
Ijwater level Is above easing,use a
1617 Mall Service Center,Raleigh,NC19699-16i7
U.Borehole diaa>Eter. A,
24b.For Itteetioe We11"c: In addition to sending the form to the address in 241L
12.WeIl constraction method:
above,also submit one copy of this forla within 30 days of completion of well
- -I,A['►/ consiructioato the foltowin�.
�i.e'a�?ger;mlan.cabl�diterxtsnst�,emJ
FOR WATER OuffLYWEM ONLY. Dhisionof Water-Resouteim,vndeMw=d1W-f mconitmt pxOgmD,,
163GMailOn-A eCenter.R111O t,NC27699I06
13a.Yeld(gpm) 7 Method of ftW g6wa AD Mi 24c.kbr Water SbpEly& ni ass,in addition to sea ft the form W
1{T,1 the addt�4,(es) aboc also!n r.t.One copy of this form widen 30 days of
13b.Disinfection tape: r F1 Amonat: _ O� completion of well conStrecdo i to•tile co>m Y hedth Rear neat of the county
witeieconsaaeted. •
Fonn GW-1
NottHCazolinaDopamaeatofSnvLonmoatelQnatity�DiviaionotWaierR�enras
. ltavised2-n2016 '