GW1-2022-08801_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: MOMT
1.Well TContractor Information:
,Uri M i C� t b C C1h_ 14.WAS ZONES
Fxaal TO DEScllmT ON,
\Yell Contractor Name
0 3&6 ft'
ft. ft.
NC 1Vell ContractarCettificatian Number L+_CUM CASING Ormald•cased wefts OR Ltit n ar )
f ERQli To I D1Ahi U TMCKNM I NIAMUM
7l wj) 3-P 2 V l 'S I'1C_ fL ft. in.
Company Name 16.111DMCASINGORTt7BING( closed- )
Z.Well ConslrnctioD Permit g: �- FROM TO DIANSEM M btAlsau►r.
Lit►all applicable well constniction permits(i e.UK Conmv.State,Variance,etc.) Q B• 9D R' zr m. Stv?�
3.Well Use(check well use):
Water Supply Well: t?'s
R80)i TO Dttll11t3'i'SR SLOTSrM THICBNPSS AtATERiAL
Agricultural �Muafcipal/Public tt. ft. in.
Geothermal(HeaEinglCoolingSctpply) �Resi ual Water Supply(single)
hndustriaUCommercial [ es deatial Water Supply(shared) M GROUT
tell anon faint To IttATERLALa T MEMOD&AATotiN r
Nom--Water Supply Well: Q' ZZn' Yl
Monitoring DRecovery M fL
i—niectlon Well,
Aquifer Recharge [Groundwater Rcmcdiation R.
19.SAMMCRAVEL Iicabfe
Aquifer Storage and Recovery Salinity Barrier PROM ToMAasrAe sntitin(pi>1atiT tifErHOD
AquiferTcst E)StormwatcrDrainage - R•
Experimental Technology [)Subsidence Control R R.
Geothermal(Closed Loop) DTraccr 28 DR17.LINGLOG attruhaddlHanais6eetsif
FRoli .
Gcothctmal(Hcatia JCoolin Retum Other ex Lain under#21 Remad(s) To DnmiPTIowadar sotUtoik ' sftLe r1
C) fr. 6 tl. Cie l3VZr ur t^
4.Date Well(s)Completed: a 3v Z Well ED# 0 ft` R. Gt'(�Y� 4-e—
So.Well Locations
NG DeV 6 rouk
Cncility/Owner Name FactTitp IDS(ft appIIcablo)
. fL .
D & Ll Les L t LoL6 T(Ji�Q1.+JQJU , PC '� R. S�F a
Physical Address,City,andZip J 2 e-7 4-1 ft R, Ur,l
Trahsyluark'a Y 532-16- �129a-
,......
r:
County Paoxl ldentWcadon No.(Mv)
i
3b.Latitude and longitude in degrees/mitmtesfiseeonds or decimal degrees-
(if well field,one latnong is sufficient) Cerdfieatlon:
V 0,L414"7 H g2".52 ' 15, 711,14 u w
6.Is(are)thevie11(s)54nmmt or Temporary Si2611110 of Certified WCU Contractor Date
By signing Phis form,f hereby cenl'fy that the nr11(s)mac(sure)constructed in accordance
I.Is this a repair to as existing Weil- Dyes or O with 15A NCAC 02C.0100 or 15ANCAC 02C A200 tVeft Comwruction Standards and that a
lfthis is a repair.fist out knoun uwlt construction infomratiott and erptain the nature ofthe copy of this record has been prorided to the we0 ouster.
repair under021 rem arks sect ion or on the back ofihisferm. 23.Site dingramor additional weRdetails.
8.For GeoprobeJDPT or Closed-Loop Geothermal Webs baviag the some You may use the back of this page to provide additional well site derails or well
t:Onsuua[on,only n OW-1 is needed. Indiwtc TOTALIY[inViSAi Of Wells
cane edon d—Ra- Yan mny ntco attach additiowd page,if a000wasy.
drilled:
9.Total well depth below land surface: t'L� 5 (B•) 24a.Far All Wells: Submit this form within 30 days of completion of well
For tnuhiple sleds thn aU depths if dj/jerent lemmp/r 3 2�00'and 2@1001 construction to the following�
10.Static water level below top of casing: 14() Uft.) Division of Water,Pesouroes,Information Processing Unit,
If scoter tesrt is abasx casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 1.4b.For Infection Wells: In addition to sending the fort to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
1t.well constracrlon method: above.
to the following
(ie.augv,rotary,cabic,dheet pin,acJ t
Division of Water Resovices,UDda%romtd hdecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Se lie Cmt er,Balelgh,NC 27699.1636
13a.Yield(gpm) Method of test. G • l fat me.For Water Suonly&111161100 Wells: In addition to seadiag the form to
the addreSS(es) above, also!submit one copy of this form within 30 days of
13b.Disinfection type: i)� Amotmk completion of well construclion to the county health department of the county
where constructed.
1.