GW1-2022-07450_Well Construction - GW1_20220810

WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only. j
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1.Well Contractor Information:
T414 4r Cr'i� lJ 14.:WATERZONFS -":w:ruv+ '.! r: 'f.':.o: 1'i 'i?t[i :]•
WellContractorName {^" t 1 ? FROM TO DFSCRi 101
tt. Sd ' 'YO #r
iG ft
C Well CoahactorCettificatloaNumber p•��r, i •§'1WOiTfELCAMG fdifi-t Io t't Wid..%ells ORLIIVER fa"'lita6le
C -� ,. UN FROM TO DLAMMR TRICEMMS MATERIAL
o'Q alb' '�3t;:-1 tic,^C:i•"r4»•.3 R. � In. � '
CompagyName J��3 i �7 L tt. G
�16:INNER'CASIIVGOR:TUBIIHG"eutlier"malelmedabo ?.� i?J1i's:!�i:.:'.T�.�'J!l"`.6.•'..�„
2.Well Construction Permit#: l 7 FROSl - To DIAMLrM I Ti$CKNESS I MATERIAL 11
Ltstall applicable well construedon powlts(Le.UIC County.States Varianca eteJ ft
3.Well Use(checkwell use): ft. ft fa
Water Supply Well: 17.SCREENaic "i: ;,?2'?'•'::iC,-;r'.at<e}:riwFi.G�L4T�Y�r;.��?:•ira�al°:iin:Citii' >i%
F DLANKM SLOTSME TRtCHNM MATERIAL
ROM TO ': •
Agricultural DMunicipalftblic C, ft. ft
_. Geothermal(Heating/C00ling Supply) 131tesidential Water Supply(single) R R in
industrial/Commercial [I•RWdential Water Supply(shared) yid GROUT °t�<<t: :s ti: >?h:.i.s"�' v�`R'S - 'e'':1 iP f�% •�.f1'r:i +i'+Al%�ie
kd lion FROM TO MATERWL EMPLACFd1ffiYtMETHODRAMOUNr
Non-Water Supply Well: ft &
Monitoring 131tecovery ft ft
Infection Well:
AquiferRecharge 0(mundwaterRemediation
Aquifer Storage and Recovery FROM.
�SalinityBarier FROM To MATERIAL ...EMFLACEMENiMErHOD
- AquiferTest 13StormwaterDrainage R R
Experimental Technology 13Subsidence Control R ft
Geothermal(ClosedLoop) OTracer '=20.tDRE:UNGLOG dhaehadditioaalliheets"ilrieeessa !r;>fi� .•re:::di3' i:' I
_ Geothermal eating/CoolingRetum) r3Other( Iainunder#21 Remarks)IFROM To DESCRUMON eclartuadoem nWmek~ '.eta
6 ft- p ft o
4.Date Well(s)Completed:5i— Y-ZZ Well W# ` ¢ ft ?ft. _-
5a.Well Location: 7,j Y,ft '79 ft ,tl go n ' ,
iA1Y1 t'S RA
RaffivownerName t FaeilttyIDF(ffaypIIwble) tt tt•
�6l'I . ..�,���� ��':PJrRnC.�lr •hill��, h��C �/li' it ft �
PhyskkWAddmss.C1W.and Zip ' � ft ft
iGl ' MI 6! UV ''V.•:2'*.::tt-.V1A;6.'•'%4rXs�.s:n:n55.i�?i: ::.•r}�;�,�_,wsu7:+..;t:;:':v�:'!z�'i:{ .i.
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County PazcelldeafteadanNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweR field,one Wong b sufficlent) 22.Certification:
6.Is(are)thewell(s)�rmanent or 13Tem ra S man WcHConaaetor Data
2 Z
po r'Y
BY s1saIng this form,I hereby cere that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or EAid' evtrh ISAt NGlCOIC.0I00 or ISANC.fC OIC.0200 R'e/1 Conrtruetlon Standartlr and that a
Ifthfsisa repair,fill outknown welt eonsin edon bFforniation and gValn the nature ofthe eapyofthlsveaordhasbeenprovidedtothe svellowner.
repairunder021 semarkssection or on the backgjthfsform 23.Site diagram or additional well details:
8.For GeoprobelDPT or Ciose'd-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. ladicate TOTAL NUMBER of wells construction details. You may also attach additional pages Unecessary•
drilled: SUBMITTAL INSTRUCTIONS
9.Total welt depth below land surface:_ �l (ft) 24a.For,All Welts: Submit this',form within 30 days of completion of well
FormultfplewellslirtaNdepthstf}ffl'ff w(amrrph;,.q oo•and2©1o0) construction to the following:
IL Static water level below top of casing: ® (ft) Division of Water Resources,Information Processing Unit,
Ifwaterlevel it above casing nse�A+^ 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter. (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit,one copy of this form within 30 days of completion'of well
12.Well construction method:,jIl r"l construction to Qre following:
Ct•e-anger.rotary.cable.diced pusb.eta)
DIvision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
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13a.Yield(gpm) � Method of test: l0 6`1 24c.For Water SugoIv&Infection Wells: In addition to sending the form to
the address(es) above, also submit one*copy of this form within 30.days of M
13b.Disinfection type: Amount: 36 b z. completion of well construction to the county health department of the county
where constructed.
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Form GW-1 Notth Carolina DepartmentofEnvhunmentalQ.W-DMsloa of Wat.Resomees Revised 2 2210I6
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