GW1-2022-09151_Well Construction - GW1_20220930

Jan. 29. 2618 10:58AM Env. Health . No• 6711 P: 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W 1 Cotmacto I11 ormado
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—'-"c- FROM TO DESCRTPMN
WellConnaotorName
- a� co.
NC Wdl CoAtMeTor Cetti6eeftri Number FI6 iopITER'GXSINti'tli risi iiiseti=xrcIIs:OR S1PEIt -ii ' b •' fa '^�:
i FROM TO DIAMEFER 7MCIMS LHATERIAl.
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C a 3 INNSR.CAS1Nfi101t'l�i[1 "•thawlit:closi+Glou' s..
2.Well Construction Permit ff: FROM TO oY�M A TAt MATERIAL
I'm all applicable well emuuuoaon permits 0.6 U1C•Caanry,Stale,Yarionce,en..) h. h. In.
3.Well Use(ebeckwell use): rt• 0. In.
WuerSp t 1'VdL•
Supply ai I DWMETt28 sLorsrrs Tu[ _ ilea.L- :
_Agriculttttal QM :paV?ublic 0 ft. R. in,
Geothermal(Reati*Cooling Supply) _Residential Water Supply(single) rt. rL
_InduatriaUCommcreiol ❑Residential Water Supply(shared) _yg gR _ ......,vr, :;;: ;F• -_y x:. .-, <_. ,,
Irr tiem FROM 70 MATERIAL EMPLAMMEMMWELOD&AMOUNr
Non-Water Supply Welh t'1 ft. >o ft.
Monitoring �RecOvety R R.
injection wen: nft.
:-)Aquifer Recharge OGmundweter Remedistion
:]''Si1s�JI►1G1tX?1fBL^^'PAC � fii"'IiiiiUle'+=•--a5;_.,�;-;;: .•.-..�..... �...r....,
lGeotAquifer$torage and Recovery OSalinityBarrier FROM To MATERIAL to MENrM>FIIOD
hesmall
AquiferTcst C)Stormwater DrainageExperimental Technology QStiltsidence Control (LGeothermal(Closed Loop); DTmcerFROM TO DISCR[VFl0N War,hantnesysotlhack sec c.(Rcubng(Cooling Renall Other lain under Remarks
4.Date Well(s)Completed: -� well IDf1 �j ft' �c:/"�— ✓ZO GGC
5a.Well Location: it o` d ft
Facilitylownm
effNa/e / T Pae:�tymN(if/uppiiea�bb (' EL n
physical Milted,City,cad Zip IL ft.
t•. ;. -- -
Couow psicelMen"catioo No.(PIN)
5b.Latitude and IoDgltude to degreeMninutedseconds or decimal degrees: /
(ifwell field,one ladlong is su6tcicut) 2L Certification: V _
W
&aL, &B'd
6.b(are)the wen(s)OU—nent or OTempor2ry Sigmrme o ertilied Well Contractor p Date
� By tipsing tlut form 1 hereby eera)y(hot the well(:)uw(k'e►O)ewunveted at oecatdaace
7.Is this a repair to an existing well ❑Yes or RDN with IM ACAC 02C.0100 or 13A NCAC 02C.0200 WeR CotmmtaloASlattdottte and that a
((rNs is anliots%flff ornlnowtwell wntowaiah*motion oud apt=the emlare of the copy of this record has been pwv(ded tithe well owner.
repair u n&r 12 rm wurh teWOM or on the bocl•Ofd&farm.
- 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed•Loop Geothermal Wells having the some You may use the back of this page to provide additional vmll site details or well
construction,only I GW I is needed. Iudicate TOTAL NUMBER of wells construction details.You may also attach Additimrel papa if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total Well depth below land surface: S (h•) 24R. For All Wells: Submit this form within 30 days of completion of well
For mulnple wells hart all depths ifdijjemat(e■ample-]@200•and 2(d l00•) construction to the following:
10.Statle Crater level below top of Ming. � � __(ft.) Division of Water Resources,Information Processing Unit,
qumrer/Orates abate 6nrfag 08"+" 1617 Mail Service Center,Raleigh,NC 2709-1617
IL Borehole diameter._-`�—(Ina
Q,, I � 246.For inlectlea Wells; In addition t0 Sending die farm to the addtesa is 24a
12 Well construction method: /fi r► It above,also submit one copy of this ibrm within 30 days of completion of well
(i r.auger,relay.table,direct push•eto.) cortspuction to the following:
Division of Wafer Resources;Undetgeaund Injeetlon Control Program,
FQR WATER SUPPLY WELLS ONLY: 1636 i fad Service Ceirlck,Raleigh,NC 27699-1636
t
139.Yield(Epm)VG Method of test: 24c.For Wafer Sunalr elk Inlec6on Wells: In addition to sending the form to
the addresses)above, also submit one copy of this form within 30 days of
13b.Disinfection lip; Amount: completion of well construction to tho county health department of the county
where constructed.
FormGw-1 North CamtmnDepv+mewatEdvmomenodWity-Division ofW2tuRwourees Revised222-2016•
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