GW1-2022-08990_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1. ei Contractor Info lion:
X\r1%1%
c,
wellContnmcmrName FROM TO DmSCRWIION
fl.
NC Well Contractor CatificadonN ft.
FROM TO D CKNESS MATERIAL
Company Namef .1"
4I ln., � �. P
2.Well Constriction Permit#:
a 0 a { FROM TO-,-- DIAMETER TffiCI MATERIAL
List all applicable well construction permits(Le.VIC,County,State,Variance,eta) R- in'
3.Well Use(che&weu use): B' In.
Water Supply weu: FROM TO DIAMETER' SLOT SIZE TRICKINESS MATERIAL
Agricultural �MunicipaUPiblic. ft ft. in I..
Geothermal(Heatmg/Cooling Supply) OResidentW Water Supply(single) % it, rot.
lndustrwCommnercial Residential Water supply(shared)
irrigation FROM TO TERiAL EAU'LLACEM UNNI FOD&AMOUNT
Non-water Supply.Well: .t<. �O R' m'�C f° � t o \ s -
- Monitoring Recovery fA - M; E� OGl lie
Injection Well:
Aquifer Recharge DCmrnmdwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM - TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage IL & i.
EVcrimental Techdology �Subsidcece Control R.
t
Geothermal(Closed:Loop) [ITracer �*
.FROM TO DES ON color,tuudu solVrack dc.
Geothermal •Coolie Return Other lamR rot admi2k ,6 ,7 b •ft.
4.Date Well(s)Completed:A (9 Q G� Weu Dxa S E P 1 Q 2 Q z
5a.Well Location: ::. U B' 8 p.r tt. 't
`mo o G (3 \-t as � r_ -
�., �', ct
Facility/OamerName Facility 1D#(ifopplicable)
ft.Physical Address,City,and Zip
'k i\ 0 OA 4 to 000b ,
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Ifwell fw one bwbng is sofficieM) ,I 22.C cation:
6-YA N t/l0 `J 1 r '54 A-1d1yVV%A-& P`^ mil 1 r (?/27 &
6.1g(are)the well(s) erm meat or Temporary .Sigoadue of Certified well Con r Dath
_ By signing this fornr,I hereby certify that the weA(s)was(were)cowftaed m accordance
7.Ts this a repair to an nuthtg well: Dyes or No Ufa ISA NC 01G.0100 or 1SANCAC 02C.0200 Well ConsnvcGton Standards and that a `
Ifthis is a repair,fnUoat Anm m well construction information and eaplairn the nature ofthe ropy ofthis recroid'has been provided to the well owner.
repair under#21 remark section or on the back ofthis form.
23.Site diagram or additional well details:
8.For GeoprobeM.Pr or Closed-Loop Geothermal Wells having the same You may use time back of this page to provide additional well site details or well
construction,only 1 GW 1 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: J` (4) 24a.For Au wells: Snbmit this�form within 30 days of completion of well
For multiple wells list aU depths ffdlf art(enample-3Q200'and 2®1M construction to the following
f I
10.Static water level below top of casing: (k) Division of water Resources,Information Processing Unit,
Ifwater level is above casing.use"+ 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: M•) 24b.For Infection wells: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following. 1
(Le.anger.rotary,cable,dseetpush,etc)
Division of water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n ` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l Method of test: 1�-c 24c.For Water Supply&Infection Weis: In addition to sending the form to
the addresses) above, also submit one copy of this.form within 30 days of
13b.Disinfection type: k�'4� Amount: completion of wo11 construction to Ithe•county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources + Revised 2-22 2016