GW1-2022-08239_Well Construction - GW1_20220419

LL CONSTRUCTION RECORD GW-1 For Internal Use only:
ell Contractor Information:
co l cS1A1 ��I JlJ�/ M WATER MNE4 I
iVc1t Coturactor Nalne FROM TO 1190UP170N
NC%ell Contractor--g i6catinn Number
-ts.ovr>ztt CasnNc itbr mnttl-casca rrene oB Lnqm er" bme
tFAWs TO I DfANW= THICHNW MATERIAi.
M I ft. 1 fn.
Company Name
26.IIVNER CASING OB TOBING( closed• ) -
2.Weft Conslrudlon Permit al:-90a — aacSS3— g— j1 FROM TO DIAMETER THICKNESS MATERIAL
Litt till applicable well constnletion perdu(ix.U1C,cotnuy.State,Variance,tie.) n' ft' zj— in.
3.Well Use(check well use): tt. ft. in.
Supply Well: M SCREM i
Water Su
p FROM TO DIAAtR7ER' SLOTSEM THICKNESS AUTERIAI
Agricultural M(Mus mpa!Mublic
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) %
Industrial/Commercial DResidential Water Supply(shared) 1tLGROUT
StTI adtx! FROM TO hUTERUIL,^ a CEt1�\TAiMOD&AMOUNT
Non-Water Supply Well: - n• Z n• 1°�
Monitoring DRecovery
lglection Well: ff.
Aquifer Recharge OGroundwater Rcmcdiation
19.SAMNGRANIM P C 1 flf analkabld
Aquifer Storage and Recovery DSatinity Barricr FROM TO I MATERIAL I EMPLaCe►>1W METHOD
Aquifer Test OStormwaterDrainage n• M
#experimental Technology Subsidence Control R• tt-
Geothermal(Closed loop) DTmccr 20.DRILUaNGLOG attach addttio ud*Am ff
FROH Geothe
rmal(Hestia Ctwlin Retum) []Other ex lain under#21 Remarks) � TO DESCMMON color, saWnmke. siv-10-1
ft (P 3 0' 0 / oYc.t—C,,u r oRQ.I/\
4.Date Well(s)Completed: Well w# G t:. or R' t
So.Well Location:
'16 1 a f-,- h N LAP
racilitylowner Name acuity IDS(if applicable) H' R'
o 161 StatliCa6ires u� e2VIi�
ft. ft. AP R
Physical Address,City,and Zip IL %
PmMaj"Una
�SD✓l -15_T �Q$ _0OZZ 2LUMARKS
I
County Parcel Identification No.(PIN)
5b.Latitude and limetade in degreWminutes/seconds or dedmal degrees: k
(if well field,one lattlong is sufficient) A22. fifou:
`// 4—G-6.Is(are)the weil(s)0P t or Temporary ified Well Contractor Date
/ By signing this form,I hereby certify that the arB(t)eves(were)constructed in accordance
7.Is this a repair to an existing well: Oyer, or Wid with 15A NCAC 02C 0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
#*this is a repair,fttl out knoxvF well construction information i explain the nature of the copy of this record has been prorided to the well timer.
repair underB21 remarks section or on the bock of thisform. 23.Site diagram or additional well details.
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts 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. Indicate TOTAL NUMBER of wells consuttcdon details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: 0� (ft) 24a.For Ail Wells: Submit this form within 30 days of completion of well
Par multiple wells lift all depths(ldif ferem(example-3@ 00'and 2@1001 construction to the following:
10.Static water level below top of casing- ;2 (ft.) Division of Water Resourees,Information Processing Unit,
!*hater lawl is abore truing,use"+ 1617 Mail Service`Center,Raleigh,NC 27699-1617
I
U.Borehole diameter•. 2 (m•) 24b.For_Infection Wells: In addition to sanding the form to the address in 24a
{� �1_ above,also submit one copy of this form within 30 days of completion of well
12.Ruch construction method: .) —"'3� construction to the following:
(ie.anger.rotary.cable,direct past,etc.)
Division of Water Resource I Unde grotmd bdection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Cent,Raleigh,NC 27699-1636
13a.Yield(gpm) � Method of test. C4 a C°d 24c.For far Sttnpjy&IeiwAl Wells: In addition to sending the form to
the address(es) above.also submit one copy of this form within 30 days of
13b.Disinfection types Amount: completion of well construction;to the county health department of the county
where constructed.