GW1-2022-08946_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW----I) For Internal Use Only:
1.Well Co tractor Information,
I&VATE ;-ZONES:. t..j
FROM TO I DESCRIPTION
Wall Contractor Noma ft.
ft. ft.
NC Well C"�rsctor Certification Number -,13,ouO CASIN9.1formulflogased*0 Is).
FROM TO DIAMFTFR THICKNESIS MATFRIAL
I ft- ft- 6dz-6-"-- SDk-ZI P VC,
Company Name r I I
1.6� MMR "SING O.R.TURING,.(keotborragitiosta�,lbo
2.Well Construction Permit N: 6 0 2,;Z,- FROM TO DIAMETER I TIIICKNPZS MATERIAL
List all applicable well COnS117101011POMIlls(i.e.UIC Countil,State,Variance,a/c.) ft. It. In.
3.Well Use(check well use):
:'IN:SCREEIV-
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
:)Agricultural DMunicipallPtiblic ft. a. :1 In.
:.)Geothermal(Heating/Cooling Supply) ffRekidential Water Supply(single) ft. ft. In.
Dindustrial/Commercial Residential Water Supply(shared) m-GROOT
Irrigation FROM TO MATERIAL EMPLACEHENTMETHOD&AMOUNT
Non-Water Supply Well: Q It, )-0 1'- ge-4&0-e- poiLrd I-1q &f-A,-
Monitoring IDRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge* DGroundwater Remedialion
Aquifer Storage and Recovery OSallnity Baffler FROM TO -1 MATERIAL EMPLACEMENTMETH5
Aquifer ft. ft.
.Test OStormwater Drainage - I
Experimental Technology []Subsidence Control ft. ft.
Geothermal(dosed Loop) DTracer •
FROM TO I DESCRIPTION(color,hardnem,soll/rock type,grain slu,etc.)
Geothermal(HeatingtCooling Return) Other(explain under#21 Remarks) CA"
4.Date Well(s)Completed: OU'Well IDN i hlni 11�
ft.
So.Well Location-
ft. ft.
E a-c—k A—n it
Facility/Owner Name Facility IDN(ifopplicable) ft. ft. r;1 -1 117
r. j r ft. ft.
cl-,k, Pj, SEP 1 9, 2022
ft. ft.
Physical Addre,,890ty,and�Zl 0
DVVQJI:�1G
County Parcel Identification No.(PIN) L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lattlong Is sufficient) 22.Certlflcuflon:
—d L
N q�'<Igef
A4j7jue
6.Is(are)the welt(s)bPermanent or [3Temporary Signature of Certified Well Contractor L) Date
By signing this form,I hereby cerlify that the Irell(s)was(were)consInfeled In accordance
7.Is this ariepair to an existing well: Dyes or [ONO with 15A NC.4C 02C.0100 or 15A AfCAC 02C.0200(Yell Construction Standards and that a
copy ofjhLv!-jj;oLdhas beenprovidedlo Ike)m1losswer.
n :fp mei lot)a)d
.ythis is a repairfill:aw kwu st.uction h i, ; eip.laftl file Halare eJlhe
repair under 1121 remarks section or on the hack ofrktifoijm' 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I Is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach.additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For nudilple wells list alldeprIts It'Offlerent(example-3@200'and 2@100) construction to the following:
IQ.Static water level below top of casing. (ft.) Division of Water Resources,Information Procegsing.Unit,
Ifivater level Is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1/0 (in.) 24b.For Intectlon Wells: i In:addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le,sugar,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SunnIv&In I lection Welig: In addition to sending the form to
the address(es) above, alsd a I ubmit one copy of this forin within 30 days of
13b.Disinfection type: N Amount: l.Lcompletion of well construction to the county health department of the county
where constructed.
ources Revised 2-22-2016
Forinow-1 North Carolina Department ofEnvlr oninentRI QuRIlly-Division of Water R