GW1-2022-08304_Well Construction - GW1_20220829

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WELL CONSTRUCTION RECORD(GW-1) For�nternatUseOnly: ;
1.Well Contractor Informadon:
jo 1+69RATEltZONES
Well CodhactorName FROM TO DIMCRUMON
Z rt.
NO Wall ConhmtnrCectifimti® t mil
r
FROM I TIHMI KNVB98 MATERIAL
CompanyI+7ama tw ft. hr. l/L
16.INNERCAMMORTQMNC(MG desed4mig
2.Weil Construction Permit;: r°I�r �l FROM TO I DMAMM I �c.[u�ss tutATstuAL
List all applIca le well construcdon permits(ir.UX,Cowl%state,Volt;UM,ere) ft. }} in.
3.Well Use(checkwen no): ft tn.
Water Supply Well: 17.15CREGN
Agricultural CrpaUPubl10 FROM I To I D srarrsiM MATBPUL
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flI
eotGeothermal(Ht tingf Cooling Supply) idential Water Supply(single) g t1i iin.Industria]lCommeroiel DResidential Water Supply(sbared) iS. -off
1IFTisaflon. FROM To BUTERiAL EMPLACHI�+iTIMMOD&A➢CUNP
Nou•Waterswly Well: M ` a• /�O u .,r
Monitoring covens &
jecdon Well: . 2 l
AquiferRecharge OCuoundwaterRemediation Aq19.
ulferSMrageandRecovery 13SalinityBarrler nxoM TO MAMMAL
Eb+1PI.ACBII'NEI�PCM$PHOD
Aquifer Test [IStomiwaterDrainage ft ft.
BxperimentalTechnology DSubsidaowContml ft. ft
ml Qeotheal(Closed Loop) Tracer 20.DWf U VG LOG attachadditfonalsheelsif
p ft.
tleothermdl esting/Cooling Return Other(eplakunder#21Remaries) FROM k
4.Date Weil(s)Comgleted: �� WeIIIDt€
5a Well LoceHon: S,
cam . e
ft
ft.
FacititylOwnerNatae FacilityIDtl(ifappticable) %
.� GS .�� �,4�r^C Ko'i• �.U�i �D� y L. % ft. AUG ,r
AhysimdAddress CCMr.=dVp R. ft.
irli:�iai P 1 r�i^p. .7 t)r'i
21.R1Rii8 .3..
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6b.Latitude and longitude in degreesf inutaslswands or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Ce ' ti :
®2_9 'g-6, 9707(.
6.TAM)the wells) Permanent or,13Temporary S of CcrflSed W Date
By slgnfrtg thisfomh I hereby CPr&that the WIY(s)ivaa(were)cam ncred In arcordrmce
7.Is this a repair to an esistmg Wes. Dyes or we WrIL ISANCACO2C DI00 orISANCAC 02C MOO Wet!ConsmccrwnStrmda ds and rhara
/fthfs lsarepakr fll out lumur well constructors rnjarmotlonmal eaplarrlthetwwrevIdw copy ofddsrecordhasbamprovfdedtathewell owier.
repalr under#2l remarkrseaon oron the ba&vfdd5 form. :3.Site diaQl'eDlor atlditloDel Well defail9:
2.For Geopmbe/DPT or Closed.Leop Geothermal Wells having the.ssme You may uge the back of this page to provide additional well site detalils fir well
construction,only 1 GW-1 h needed. indicate TOTALNUbMER ofwells onnstnretion detal�s..Yon may also attach additional pages if necessary.
drilled: SMMlT'r T>1 IS I'RUCt'r011T
Formull well depth below lands ant(e: �2 (€t) 24s.For.MWells: Submit ibis form within 30 days of completion of wen
Aorrnsldple welra lust aIIdepths rffirent(example-3@200'mtdl@I00� constructioaiothe following:
10.Static water level below top of casings (ft.) Division of Water R�esoorces Tafornmtion Prncessin Q�
Ifwater level is above casing,use"t" g to
1617 Mall Service Center,Ratelgh,NC 2769XI617
11.Borehole dian¢eter: (in) 24b.Fur infection Wells- In audition to sending the form to the address in 24a
M Wellconstraction method: _ p /'r_<�l Dove,also submit one copy of this form within 30 days of completion of well
(Le.auger-racy,cable,directVM%etc-) : constmetionto the foIlowing
FOR WATER i3pPpLY WELIA9 ONLY: Dlviston of Water Resources.Underground IgpecSnn Canirnl pregaana,
1636Mai!ServiceCenter,jwei h NCx169Xi6M
13a.Yield(gpta) Method of tesu w" 24c.F—w—Water SuMI &T gem-on Wells: Ift addition to sending the form to
p TO
the addresses) aboveti also!submit one OW Of this farm within 30 days of
13b.Disinfection type: / Amo=u__ L J O L,1 c e 5 completion of well construction to the county health department of the county
where consnucoed_
Foam GW-3 NorthCaroliQaDepa�rantaPEavironmantalQaatity-Divieionof WBtm Resotaees Rovised2?2 2016