GW1-2022-08536_Well Construction - GW1_20220428

Jan, 24. 2018 10:58AM Env, Health No, 6111 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Interne)Use Only:
1.W 1 Cootracto Inform floJ�
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WdlConuactorName Boom TO DESCRWIrON
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NC Wen Contrse or Certification Number '13:;UU:fBlr�ikSLSiG ftilCmidHta�ed""1[s:OIt ' fii .M o I Je.I t a &�M'd se b r!ta s
� FAOM TO DIAMEUR THIMESS MATERIAL
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2.Wall Construction Permit tf: � FROM TO OfAM99 TRTCRNESS MA ERUL
lltt all applicable well ro wnterion penntu il e.UIC,County,Slate,Variance,ex) n• h• In.
3.Well Use(cbeckwell use): n. tr. m.
WaterSa 11'YeU: �12•:SQtE$tel::������.�wM,:..k���.:, :...^.,,����:<-F�_:__•_`=_=_'
pF y SItpM TOI DUMErOU I SLOTSIZE I ThICKNUS MATMIAL
_Agricultural Mwicipal/P'ablic 0 ft. ft in,
Geothermal(Reating/Ceoling Supply) Residential Water Supply(Single) ft. fL in,; .
_htdustrieUCom icreial Residential Water Supply shatat — . ..,„�.Zo.�• �_ ,,_
In•i tion FROM TO MATERIAL EMrLACEMF,N_1'MErHOD&AMOUNF
Non-Water Supply Well: ft.
Monitoring ❑Recovery ft ft,7nJecdon Well:
It. R.
Aquifer Recharge []Groundwater Remedietien
19:4AVVIGFAVE iPACK- Fa6064'l
e':=�:•-a=;_�;:.-R s• T•.�:
Aquifer Storage and Recovery C)Selinitylildrrier FROM TO MATERIAL EMPLACEMENI'M1Mou
_. AquiferTest 'r)StotmWeter Drainage ft.Experimental Technology Subsidence Control n R•
Geothermal(Closed Loop)- OTraeer 20-j i01Va1:laG aiw iddtt faiii:i6ietr•wi—ftliiii''
_ Geothermal(I3eatingfCoo"fiigRe -)OthTL lain undue#2l Remarks FROM To fseaurrroY afar hndnespraWnKlIs see etc.
G ft e R' Clo
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4.Date Well(s)Completed:,?�'fl?1 Well ID# C
Sa.Well Location —
' ,
1 to t3
Facility/owm(Na c Faci ..itrtnappttaable) a n. P
r
.7 Gt Ph e 4h �� S Ol+r 2 n. 1
P ical Addmss Caty,sad Zip .C
LJ�/A OIL TIT. _ _._ ..�_ ...... -
Conaty Pa,erlldemi6ca<ioa NO.(PIN)
Sb.Latitude and longitude in degreea/minutes/seconds or decimal degrees. J
(ifwell6etd C 22.Certification: -
j
6.Ix(are)ilte well(s)O Permanent or OTemporary Sigmnue ofeerrified Well Contractor I Date
By signing tide form I hereby certpy Thar the WWI(s)w,os(were)ronsimeted flu accordance
7.Is this a repair to an existing well: []Yes or QNo woh 159 NC IC 02C.0100 or IM MUC 02C.0200 Well Conrinictlon&Vndotetr and chat a
((this is a repair iff orn Imown well ewnmuccian btfarounion and aplaoi the naltme of As copy of this rewftf has been provided to the teell owner.
repair under 971 renmrkc reerion or on the back of tits form
23.Site diagram or additional well details:
&For GeoprobeMPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional Avli site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL,NUMRBR of wcllg consttuction details.You may also attach additional pages if necessary.
drilled: 2 SUBMITTAL INSTRIXTifJrNS
9.Total well depth below land sorhm: J (h•) 24a, For All Wells: Submit this form wi0un 30 days of completion of well
Form�lnpfe+lens)trt all depth.ifdii ferent(oomple.3®It10,m d i@J00') construction to the following:
10.Static water level below top of casing: �J (ft.) Division of Water Resources,Information Processing Unit,
ffwarer lewt is obm'e eafine tsse"+' 1617 Mail Semettehfer,Raleigh,NC 27699-1617
1L Borehole diameter. (in.) 24L For Iniectlon Wells: In addition to rending the farm 4o the address in 24a
12.Well construction method: r I above,also submit one copy of this fbim within 30 days of completion of well
(i.a auger,rotary,cable.ditteel push.etc.) e0nsp'uctipn to the following:
Division of Water Resources,Underground injection Control Program,
FQR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centee,Raleigh,NC 27699-1636
c
13e Yield(gpm) Method of test: U rNm For Water SunDty&Inlecdon Wells: In addition to sending the form to
address(cs)above, also submit one copy of this torn within 30 days of
136.Disinfection type: �!r Amount: completion of well construction to rho county health department of the county
where eonstrutted.
FormGW-1 Nocth Castilian Dgmtft toffavimameadQaaliry-DivisionofWaterRcsomres Revised2-22-2016'