GW1-2022-08832_Well Construction - GW1_20220912

ti7t)JE�NSTR J[j% Lq_lu (��-1) For Interval Use Only:
L Well Coontr ctorInformntion: -
/�/� Y/1P�✓ 19.WATFdt7oNE5
IaIDTf 70 SME
well Connhha/clar Nonac � Ra_41 I 71(� R 7ISRNowellCounaatorCertiScatioaNurnow 15.OUPERCAWNG f " lls ORLWRR de UanbIa -
YAOIONWELLCOMPANY,INC. FROM T DLtb=TKi CENEEa- MA.,RUL_
MSC=REEN
C®panyNeme j/y{�'LrG eot2.WellComstructiunPermit#: WEKF ^®1VSre;% ?��2 - _ nrAMaxaR THICHrmss Lis,allo 11mble wallconstructionpermits(Le.WC,Covnty,Staley Yarianm etc) �j m'3.Well Use(ebeckwdl use): imWatersupplyWclh DWusralt SLOT sv.E Tmclaims MATERIALOAgricuitmalOMunicipaWnblicia.
OGcothernlel(HtatingiCooling Supply) Mtesidentlsl Water Supply(single) R• - In.
oladustrial/Commemisl QResidential Water Supply(shared) la.GROUT
OLri 'on UWells>100,000 GPD snots- xo MQATERIAL EMPIACEMENTASLrrnoDsAMOUNT
Non-Water SupplyWdl: tt' 13 R' lY ). " ,
Omng l7Recovery R R
Injection WdL• ft _ R
OAquifer Recharge OGreundwater Remediatiou ly.SAPIDIGRAVEf.PACK do liceble - •
OAquifer Storage and Recovery OSalinityBamer mRou xD ruraunL - I EW1ACEMZNxM=OD
OAquifer Test OStormwater Drainage R IL
OEbcpermmental Technology OSubsidence Control R 11 ®'
oGecthennel(Closed Loop) OTracer 20.DRIL1WGLOG atNchadditional sheelvif necessary)
OGeothecmal Meetiag/Cooling Return) OOther(explsiaunder621Remarlm) FROM To nsslmffaoN a,mr hvrdvev.oVmra s�.eR: ^
/ g V R . IL
4.Date Wells)Completed: r( - 2L We11IDi1 Q9_ ar SOU fL a' ;/4V
Sa.WellLucation: Phone 36, r
R -
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• �O�a 609 All it ft
Facility/Owaallome PecilityID#(sfapplicable) 'K fL F
ft R
uo..... .. ,,.. '
PhyscalAddns as,City, ,1Yip
21.REMABBS
ya a�Jif.LGe ( t) o . 3v 1 f
County Parcel IdenfihoatiaaNa.IPIDI) /n+
5b.Latitude and longitude In degreeslminutes/seconds or decimal degrees: ?ra_ -Ku2 -. Y
(dwell field,onelet/longis sufficient) 22.Certification: '
fir" iv, i YS N 8Cs" 54 V• 1s CZ w 2 2
6.Is(are)thewell(s): RIfermanent or OTemporary gnam`e of CmtiEcd Well Contactor Date
By rignngthlsform,Thereby cer6(y dial fhewall(s)was(wen)constructed In accordance with
7.Is this a repair to an existing well: Byes or Mo ISANCAC 01C.0100 or,15ANC4C 02C.0200'Well Canstrvdlon Standards and thal a ropy
Ifdhis is arepalr fil/aul known well construction btfornatian and erylain the nadum ofthe of this recordhar bemprov/dedia the well ownm
repair under921 rrmarkrsection or on the back ofthisf=. 23.Site diagram or additional well details:
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
coustuction,only 1'GW-1 is needed Indicate TOTALNUMBER of wells (add See Over'in Aomori.Sox).You may also attach odd oml pages fuececsary..
drilled: i }
nn �1 ?A.6'UB]VII7.TAL'INSTRUCTIONS
9.Total well depth below land surface: X d— A) Submit this GW-1 within 30 days of well completion per the following: 1
pormvltiple wells list all depths br&Frr i(aampte-�200'o 52J@1001
10.6tatiewater level below top of casing: 7U (fL) 74a. For A0 Wells: Original form to Division of Water Resources (DWR),
10.St r1evellsabove el casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter- (in-) Bit Off: s 3 21b.For'Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,NC 276991636
11 Well construction method: AIR ROTARY '
(i.e.auge,rolary,cable,d reetpush,eta.) 24e.For Water Supental h and Ooaa-Loop,fthe county Return Wells:Copy to the
county environmental health depertinent of the wlmty where rDstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 I GPD:Copy to DWR,CCPCUA
276R i
Permit Pmgrem.1611"MSC,Raleigh.NC 6
13a.Yield(gpm) SO Method of test: ri 911 I
"� C. / [[��� 2�
70%HTH L' OZ DATE SITE VISITED: T. ^v+- �
136.Disinfection type: Amount
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