GW1-2022-08992_Well Construction - GW1_20220919

I
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only.
1.Wen Conk actor Info n:
FROM TO D CREMON
wellCoouaemrxame tiv ft.
NC Well Contractor Cectifi ation Number
0 & �-�. IL b f�� U V 1�0� MATERIAL c
CompanyNa�
2.Well Construction Permit#: o o� ''`O® � () FROM TO aIAMETER THIc2aam MATERIAL
List aU applicable well conshuctlon permits(La UIC,C wity,State•Var*owe,eta) �• fL j., fa'
3.Well Use(check well use): IL & in.
Water Supply Well: FROM TO DL►MEIE1t SLOT sr� THICFINFSS MATERIAL
Agriculdual �Munr blic ft % is
Geothermal(Heating(Cooling Supply) 'denial Water Supply(single) f % to.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERLAL EMPLA OD&AMOUNT
Nun-Water supply well: 'O IL p & Ag
Ota�
Monitoring Revery lit. it,
Injection Well: �
Aquifer Recharge 13Cmoundwater Remediation
Storage and Revery 13Saltnity Barrier FROM TO MATERIAL EMPLACE NT METHOD
Aquifer Test DStomrwater Drainage f ft.
Expetime�l Technology 13Subsidence Control It. R
Ceoth=W(Closed Loop) Tracer
FROM TO DFS ON color,hardo eoa/roetc ebe
Geothermal Coolie Ream Other lain under#21 Remarks 0 g,
—
4.Date Well(s)Completed: O Well ,)`" . I °'1!a ��.,-1.3 ft. it.
Ss.Well Location: G
SEP .1 � 2022
Facility/OwnerN a ifyll?#(ifiap�lcc'a� '_`::-1:0 "ii 1t.' tl.
Physical Address,City,and Zip i i�
wy�e�w� � q6� 6+1 Q R! 4u
Counly Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(cfweII field,am lat/long is sufficient) a �� 2L C cation:
31 )°1 t N `6`a � w .1 t Act as
6.1g(are)the i!gq) tr;Fent or Tempo;�N,
Signature of Certified Well Con for
By signing this form,I hereby cafify that the wfl(s)was(were)constructed in accordance
7.Is this a repair to an existing wen: QYes or with 15A NCAC 02C.0100 or IJA NCAC 02C.0200 Well Conshucdon Standards and that a
Iftbls is a rgWr,fiUout bmm urB consftwil iafotneallon and explan the nature ofthe copy ofMb record has been provided to the well owner.
repair under il21 remarks section or on the back of dds fom
23.Site diagram or additional well details:
8.For GeoprobeM.PT 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 1 GW 1 is needed. Indicate TOTAL NUMBER of construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: \ (�) 24a. For All Webs: Submit this form within 30 days of completion of well
For multiple wells list aU depths if dJf jmw(auanple-3(a)200'and 2Q100) construction to the following: I.
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
Ifwnter level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Webs. 1n 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.
(Le.auger,rotary.cable,direct Push.etc.)
Division of water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 2
- 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) 0 Method of teak `_ 24c.For Water Supply&Iniecti I I Wells: In addition to sending the form to
the address(es) above, also submit one copy of this.foma within 30 days of
13b.Disinfeetlon type: Amount V To completion of well construction toy the county health department of the county
where constructed. i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016