GW1-2022-09242_Well Construction - GW1_20221003

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WVELL CONSTRUCTION RECORD(GWV-f.1 For fraternal Use Only:
I.Weil Contractor Information:
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Flog TO ooit
1Veil Contractor Name
NCWeII('nattactarCertifieatianNttmher I&0Vr=CAMX0dbrmuM4m.edwetfs ©2I1MP.gHfa
r,� 011 To D THICtt i<iAMMAL
Company Name l�t� r ', ` e' it- 9 Et- i t' O � Y V Q I
16.12WERCAMGM.F[iBIlHG(eotT�alctased-1
2.WeQ ConstMeflon Pecmit 9.1 FROM To nraMEM 17MCKNM MATERML
MI a1f appf icaLle wdl construction permits(i e.FDIC,Calua_V.State.Variailre,etc.) R• 3( in. I e d$-e s�
3.Well Use(check welL use): D' D' in.
Water S�,pty Well: 17.sCRIMM
FROM TO DLU SLOT SCLB TSrCONESS RIATERTAL ,
Agficulnuat ' MtuticipaVPublic ft. R. rtt.
Geothermal(imfn iCooling Supply) [3Residcntiai Water Supply(siaglc) R. fE. in.
IndustriallCommerciat DResideatial Water Supply(shared) I&GROUT
WI ation FROSS I To 51ATEPJAL E1MACEMN MEFROn& IOU
Non Water Sup*Well: o tt ft. - Dist rc' Forf
_. Monitoring ecoverY ft It.
kdection Well:
3Aqufficr Recharge E3Groundwater Remediniion fL
19 SAMMMAMMPACS Usable
AgotfcrSwmnge and Recovery E33atinity Barrier FROM To ars�rar. IIHPfAlltTi i&1FIh3ErHpD
AquiferTcst E3Stotmwatct-Drainage n• M
Etpadmental Technology [)Sribsidence Control & ft.
Creothermal(CI Md IAop) Dudger ZO.DRiTi.1d1YGLOG otltttheddidtamlydreeaif
Gcothennal f Heatia /Cooli Return) Oflter ex am under ill Remarks) Est TQ nFscRteTcot�Immr saitleattc size etcl
6 ft' 31 �• 0�bur r.
a.Date Welt(V Completed: ' won M 3 t R' S' "• h /e " �.a�
Se.Well Locati
rwility/Owner Nam Facility ID#(ifanUcabte) fL I t
Physical Addrez,City*andZip tL n'
ZLRENABKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degreesin invtes/seconds or decimal degrees:
(irwell field,one latliong is sufficiem) 2L Cerdlieation:
3so 13`as.bus'l90" N92® 20tVV- g4ijb3 ' W -
6.Is(are}titerveU(s) yermanent oremporarq igirdRttGafCeitifledNellConuactor Date
By sighing thisform I hereby Certify that the K*Ufs)nits fuvrel cotivrocted in acmdance
7.Is this a repair to an emdsting well: (3Yes or 1>6/ with ISANCW 02C.0100 or 15ANCAC 02C.02W Wclr Coastraction Swndsrdr and that a
It tliir fs a reparr,Jrll out knmvz.cell construction information and erptafn the nature ofthe copy of dads record has been praeided to the wait mate,.
repair under021 rrmarksmtion aranAe barkofAisform. 23•Slte diagram or additionet well details!
it-For CanpraboMPT orClaced-Loop Coatharmal WAattaving the gala You tttay use the back of this page to provide additional well Site details or wn11
construrton,only 1 OW-1 is DGMUd. Indicate TQTAL NtiMDBR orwcras construction detaas_You may also anneh additional pagan if necessary.
drificd; SUBM3TTALIN33RI. u� DN.C��
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9.Total well depot below land smrPace: tn) 248.For All Wells: Submit this form within 30 days of completion of well
For multiple smells.Un all depths f f cVerent(emmplc-3W00'and 2@10a) conwaction to the following:
10.Static water'level below top of�ttug: o[ i� fit,) Division of Water Resourms,Information Processing UW4
Ifumerie►rlisabairaaring,we"+' 161'711MtService Center,Raleigh,NC 27699-1617
U.Borehole diameter. to. 2'L (in.) 24b.For Whellon Weiss:i In addition to sending the form to the address in 24a
12.Well construction method. [?C-3 La� above,also submit one Copy of this form within 30 days of completion of weU
'•'*' •�`�J'- t-•—•�-�-•• constriction to dhc following:
(it.aagv.mmty.cabrc,daoccpash,uc-)
Division of Water Rem",Under inuid bdetfion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1Q6Kd S Irx MCeHt%Ralel^NC 27MI6M
13u.Yield(gpm) 16 tAM Method of test:Qdl- (016tUt 24c.EK Op &&Ltectfon Welly In addition to smiling the ft ma to
`` tho addM(es) above,also submit one copy of this form within 3o days of
136.Disinfection type: Y`C Amounts a� DS Completion of well constmctim to the county health digiattatent of the county
_— where consuWad.