GW1-2022-09226_Well Construction - GW1_20221003

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ctor Certification Nnntber ft ft
Well &Pump, Inc. 15:OIU=ZM. d.SIlKa,fn?tiiniti-'d seq*aRJ IMJER bii W'-'licahla)
FROM TO' DWvXTER ! I:THIC$iMS I ATATMUA•L
nyName ti ft 0 ft 61/8/ m•, sd,21 pvc
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Olt•TIIBIN.G: •eoth'ermalclo's@d-rod'- ;• ';c:•'�•:'
L:WeII Construction Permit 1b.-IM'M
#:( )' �0�3 �' FROM To DIABO= ! m Mc uss MATERIAL'
Lid aR appl cable weE canSlruCrian permits(i a UIG Cavan State,Variance,era} ft ft. in.i
3.Well Use(check well use): ft ft in.i
Water SmmppIp WeIl: 17_-8CREIT',_
Agricultural FROM TO DIAMTSTER SLOT SIZB .'THICKMS ~MATERUL,
�Municipal/Public � `ft in.
Geothermal(Seating/Cooling Supply) �iResidential Water Supply(single)
ft fc is
Residential Water Supply(sbwad) rm Ttm
hon 18:GRODT'.
FROM TO ATA•rr AL I RhdTT ACEMTNT METHOD&AMODNT
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Non-Water SnppIp Well: o �• ft .
benionite• poured
Monitoring Recovery ft ft
Injection.WeTI
_ Am,-Recharge MI CneundwaterRemediation ft ft
Aquifer to,
and Recovery DSalinity Bawer :19:S iND/GRAVEI PtLCK if "'livable •': ,': ;.';_'' : . .:i': "•::':
FROM TO MATERIAL Eil2PLACBMENT METHOD
Aquifer Test 1IStommwater Drainage ft ft
i ExPenmeutal Technology E3Subsidence Control ft ft
Geothermal(Closed Loop) 1ITracer :2D.DRILI IrTGS OG'(atta}is3dihorisi s]ieets�faeces .
c Geothermal(Heaiing/Cooling Reium) 00ther(explain under#21 Remarks) I FROM To DESCRIPTION(color,hardness,soatrotk type6 grzm sbr,eb%)
4.Date Well(s)Completed: 1 s r 2G Well ID#/ t S• ft a 5 ft
52 WellLocatio A5 ft O ft
0 ft
Facility/Owner me Na
� Facility IN(ifapplicable) ft f
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4 a?d55 ft ft 022
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P steal Address,City,a&Zip ft
� °2Ii'R'F.h?d RTCC" `•i. _ - _ �'�J ulii
County Parcel Identification No,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(¢/well field,one lat4ong is sufficient) (�
•N Cj
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6.Is(are)the we11(s) Permanent or oTemporary Signa e f ed WeR Contractor Da
7.IS this a repair to an existing o vng is form,1 he?ebv certzfy that the weRN was(were)constructed in accordance
P well Yes or �No wuh 15.4 C 02C.0100 or 1S 4 NCAC 02C:0200 MaH Construction Srandw-&and Mora
If this is a repair,feII out known weII consttuc8on information and explain Die nature ofthe copy ofthis record has been provided to the weII owner.
repair under#21 remarks section or on the back ofthis form.
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 1 GW-1 is needed Indicate TOTAL NUMBER*of wells conshnction details. You may also attach additional pages if necessary.
drilled:__ y
O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 d j
For mulnple'we&&Iag As'dl Brent �,!e- (ft) 24a. For All Wells: Submit this form within 30 day§ of completion of well
�p ( p -3@200'.aid2@10D�
construction to the following: ;
10.Static water level below top of casing.
Ifwaie'level is above casino use"t•, (ft) Division of Water Resources,Information Processing Unit,
11,Borehole diameter: 6
1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
(�•)
24b.For Iniection Wells: 7n addition to sending the foffi to the address in 24a
12.Well construction method: LA (✓� above, also submit one copy of this form within 30 days of completion of well
0-e.auger,rotary,cable,directpush,etc.) construction to the following: i
Division of Water Resources,Underground Injection Control Program,
ROR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
.3a_Yield
(gpm) Method of test air pressure 24c.For Water Sunuly&Infection Wells: In addition to sending the form to i
the address(es) 'above, also submit one copy of this form within 30 days of
3b.Disinfection typ Amount 128z� completion of well construction to the county health deparbnent of the county
where constructed_
l
¢m GW-1 North Carolina Department ofF.nvironmental Quality Division of Water Resources - l
Q h'- Revised
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