GW1-2022-08531_Well Construction - GW1_20220428

Jan, 29. 2018 10:58AM Env, Health . No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1) or Internal Use Only:
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NC WellComme or CertificationNttmbar I61.Q11tEACASLY(i:iriiGmidH''-e7weIIt:OIt fii"WAtde I»A
i FROM I TO - DIAMETER THIC&NESS MATERW.
D�eiYS I Jc'(� >2 - cSE rrlcC ,I rt. 100 _ VC.;
complatywiffle
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2-Well Consiructlon Perndt N: M To I ohtmma Tmomm ItiresERrAL
Llst all opecabre w it conrintedon peentrs(t e.EM..Cmmry.Scare,Variance,ex.) R• R• in.
3.Weli Use(cbeekwell use): n• h. tn.
iliffiation
ster5a ! 1,Ye11:PFy '1'0 B OTSME Agricultural Municipsymlic 0 R. R. w!
Geothermal¢MeatineCooling Supply) Residential Water Supply(single) R, IL inIndustritYCommcreiol Residential Water 3 l shorod FR01*1 TO~ YtAURIAL I LttPLACEMs'Rt x=oD @ Am5—wr
ilon-Water supply Well: n. rr. t f ' ��
Monimring ❑RetoVery R. R
Injection Weil: R,
Aquifer Reettarge []Groundwater Remediation
ax�icaJnreltil,>vecPne � r�i"'Rc6dti:=-:.-.=;_�;::-:�x�.-..�•.. ....��-�::;:-�=
Aquifer Storage and Recovery DSalinityBarrier FROM To MATERIAL EMP4ACRhr6MMLM
Aquifer Test. -MStormwaler Drainage m R
Experimental Technology 0SubsidenceConlrol fc R•
Geothermal(Closed Loop):.g 13Traoer i�20::D EW91:t aifieh eudltioiuirelieetr�ff W-Fn
Geothermal(HearinCa�Itni' .___- `.••' "�=-:_=
..RennstOther ex Iain under li2l Remarks FROM To OfscourrroN Colenhmtnar,seltttetk i¢e err.
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4.Date Wells)Completed ` well ID# C(Cl tc C/O ft. �, '°'r"e
5a.Well Loeatiom l C<I -3a0
�cw i' r e _
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FaclrivowerName PacFidrod(.fippticaote) R
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Phpiwt Addteu,City,add M b w / �" R. M -
/ n eL l i�e, _
Corny .h Fairer Idetaitieatioa No.(PIN) ' -- =-- __- .�J''A�Y �� r•o�> >y v,..^.
Sh.Latitude and longitude to degreeMnioules/seconds or decimal degrees:
(irwelleetd.one ladlmtgiasufficient) /t� Of ? 22.CertiGcaRon:
?0 N� (/ �. V L J �/�WLu
6.12(aTe)the WEU(s)OPermanent or QTemporary gtgunnoteettiliedWellContractor Date
By tig,tiag rh;:/arm I hereby eertny char the wall(k)um(wre)mu mmied is aocordaace
7.Ia this a repair to an existing well: Yes or No with 1SAW-AC 02C.0100 ar 19A NCAC 62C.0200 We11 Cotsmnwien Standtnett and that o
(/this is a repot.,Jla om knotwtwelt eenst ucriaamfara argon m erplam the notrae ofthe eopyofrhtr rocnrd has beenprotyded ro the tedl oww.
repair order 021 mamrks teettoa or on the back of thtsfomn
23.Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the beck of this page to provide additional Well site details or well
construction,only I GW-1 fs needed.Indicate TOTAL NUMBER of walls construction details. You may also attach additional pages if necessary.
drilled: SININUTTAL INSTRUCTIONS
9.Total well depth below land surface: so � (11 24s. For All Weft Submit this form within 30 days of completion of well
FarmuGrple wens/ut a►/deprht ifdiffe>ent(eduyle•3(d)200'and z®!OQ) construction to the following:
10.Static water level below top of casing: (R-) Division of Water Resources,Information Processing Unit,
ywarer level a above emhig;we"+" 1617 Mail Service Centers Raleigh,NC 27699-1617
IL Borehole diameter. (in.) 24b.For Injection Wells: In Addition to sendhtg the form to the address in 24a
4 r I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ia NBA. Y.cable,dtrtcl push eto.) -
Division of Water Resources,Undergraund Injeedon Control Program,
F9R WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(aptn) Method of test: ! 24e.For Water Supply dt lnlectton Wells: In addition to sawing the form to
the address(cs)above, also submit one copy of this form within 30 days of
13b.Didnfection type: I r Amount: 2jC1xpScompletion of well construction to the county health department of the county
where constructed.
Form OW-1No#hCarainnDgwt&astafFsomdmeaW Quality-Division ofWaterRwoum I Revisod2-22-2016'