GW1-2022-08306_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD(GW-1) For Inumal Use only:
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1.Well Contractor Information:
MNIp
14LwATMztxM
Well Name FROM TO DAWN
NC Well Contractor Cartificalim Nom6er yq pm=CASING maMi used wed OR LII�ffiB
1 FROM TD DI IMM MATEBTAL
COMP,,y14am, -
16.E%4 CASERGORTtIsnvG
2.Well Oonstruct ion Permit#: O t 0 1-/-1 FROM 110 1 DIAi1Rffit. I THK2aMSMATFJtiAL
List afl r>ppliaable wa aomtntchon pernaft(ee u1G C s crier i ll 1 1A I-
3.Well Use(check well me):
n n in
water soppr9 Well: lz SCREM
FROM ITO I I DIAM6'iFR SIMS= I 'fficzIUM MATERIAL
3Agricultural 0MumicipaliPublic U n n
Geo&etmai(xS1Coo1mS Supply) Residential Water Supply(single) n n in.!
Industrialycommercial Residential Water Supply(shared) M GROUT
FROM 170 MAiEBIAL ffiId�VThIEiHODdAMOIINr
Non-Water Supply Well: D-[ Recovery n ap n
Injection well: —
Recharge ❑tmwmdvvataRemedia2ion �g n SANDXMMappncAft
9n.1b,Storage and Recovery E]SWinky Barrier lamvSL PACK dMATEMAL EMPLAC�iTMrilHOD
]VAFffWTWt DStoffiwalmDrainage n It.
Experimental Technology [)Subsidence Control n n
R
eothermal(Closed loop) D"f— 2a DRILLING 1.OG attlleh addifioml sheW if
FROM TO DESCF&MON hr.Iordmm=WE.sel< me,�
eathe�al(He�mg/Caoling Ret®)'. Other(explain�a g21 Remadcs)
- c r� S�•4 ;�.
4 Date
wEn�sj compkteaa 02`
Sa.wen Location:
Fact Name FaciW EN(dapplic") n n
Phys ealAu&,City.ands
.2L R>Q►lA>a>;s 5P .0 ,
2022
C-013r Paeel ldeati5wtianNo.
$b.Latitude and lougitndE ID degree/minntes/semnds or decimal degrees: :
(tf Welt field,one Id/long is sntficwnt)- 22. Cation:UD,
`
6 h(am)the well(s)SPermanent or Temporary S, of w Daze
hy.signurg this form,I hereby con*that the wells)was(*vm)constructed in accordance
7..0 this a repair to an existing well: [)Yes or Jallo with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standv*and dud a
Ythis is a repair,fill oat brown well conmuction utrormarran and explain the nature ofthe copy ofdw record has been provided to the well owner.
repafr under I21 reminds section or on the boat of thisfornr. 23.Site diagram or additional well detals:
8.For GcoprobeMPT or U...d-Loop Geothermal Knells having the wine 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, construction details. You may also attach additional pages if necessary.
drrIIed. 1 SUBWUII AL INSTRUMOMS
9.Total well depth below land surface: 3 t-1 5' (n) 24a. For All Wells: Submit this form within 30 days of completion of well
For mdtlple wear ti t andgrths ijdi9eaent(a�mnple-S(t�2o0'and 2�ItXll _._. . won to the following.
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10.Static water hsvel below top of easing: J?C (ft.) Division of Water Reso Information Unit,
7fiwaterlevelisitbiive. .niece, Prod
casu'g use-+ 1617 Mail Service Center Raleigh,NC 27699-1617
11.Borehole diameter. 1 (rn.) 24b.1?6r Infection Wells. In addition to sending the.form to the address.in 24a'
i2 weII constracHon method: above,also submit one copy of this form within 30 days.of completion of well
60nstrii64ioa to tlie'fonowing
(ca atig..c66k ca�kr;heel push,etc-)
Division of Water Resomrces,UndergrounduIH' Coatiot
_ - � ..1� J� � ..,
FOR WATIIt SUPPLY*Mjs ONLY: Marl Service Cep,Raleigh,NC 2709-ICK
13a.Yield(gpm) Method of testi 24�"For Wain Smarms&Infection Wells )a adilrtim to sending the Spun to
the addresses) above, also submit ere Dopy of this fDffi within 30 days of
13b.Disinfection type: D (F f� Amount: I Z completion of well suction io;the county health depastment of the county
where
Farm GW-1 NorM Carolina Depmtmedt of amo QuaW-Division of Water Resontoes Revised 2-22 2016