GW1-2022-09342_Well Construction - GW1_20221007

i
FELL CONSTRUCTION RECORD
i This form can be used for single or multiple wells For Internal Use ONLY:
1-Well C ntractor Information:
✓�[l 14.WATER ZONFS
WzU Contractor Name FROM TO DASCItUMON
2f 1q — � /0 ft 72 it. f el N
NC We0 Conha tifi ft it
c,orCaCation Numbs
FS.•UTIiER,O farhrtalE,c2Md.pdh 0R.1jM.RAf2 ties q
D arneft Well Drillings One. FROM DL9biETpR
1'HICnIVESfi MA
Company Name � R
2 it 4. Spot—Zb TaRUL
IsaIIIiPR CAs dvG•OR.rvBnvG eon VC
2•Well Construction Permitti:�S W P Qt9D7q°► . 20ZZ FROM To D�,tt efrual.ela4edl'"
List all applicable veil consrraaion ft THTCHNESS MATEEtiAL
Perms ox-Cormly,S1014 Variance,eta.) R in.
3.Well Use(check well use): ft ft
Water Sappty Well: 7T'SGRggN:'
❑Agricultural FROM TO DIAMETER SLOTfiIZE
❑M�unicipaUPublic. ft R in Tlllt� FEMs arArlrtlAL
l7Gaothetmal( mercg/Cooling in.
lHftrsidential Water Supply(single) R ft in
Obri dtion mmercial ❑Residential Water Supplysh
" Obri tition ( at+ed)
IrROM
Non-Water Well: ft TO MatERur EMPLACEMPA•rMEIROD''&AMOONT
ft arne our
Monitoring men4
lajeclion Wc1L- ❑Recovery ft fc
❑Aquifer Recharge &
OD
❑Gmundwaterltemediation '.19cSA1+[17/GIYAYrRL;:prti� i
❑Aquifer Storage and Recovcry I ,titbtile
FROM ro MATERIAL
❑Salinity Barrier meiruceniTxrlHere
❑AquiferTesE ❑StormwatcrDrainage ftPL
DExperimemalTechnology ❑Subsidence Control R IF
❑Geothermal(Closed Loop) ❑Tracer :•'1 i11 LilYt;°I;UG:aitirclitid8'i '•atietu:itn ..
E3Goothermal(Heating/Cooling Reh7m 11t0M To DESf�tIC1TON cub hand„ z 'DOtha{explain under#2lRemarks Q ft z ft zoiVroek rt'CIetc
4.Date Welts)Completed: o
S'02�?- -Well �iC�4 (, ' Q- ft ft ` ' 1
Sa Well Location: ft: S� It
R-dy),,%l� /Qoq sou tt ��
Fa9111Y1UwncrNanI -�— ro (C
FzeilkV MR(ifipplieablc) R
iS21ova �t�� (I,IUnIG� ��l n rt
Physical Address City.and Zip ft r
County � ..
Darnel ideia5catiou.No.(Dial)
56.Latitude and Longitudcindegrewminuteslsewndsurdecimaldegrees: tf `;;
(rTtiveU 6eid one ladJoag is sufScient) - '"WUn:N 71w6"Ufare)thew.ell(s): tll�rmanent. or OTemporaiy f of d ' anoatxor
By sr);rring Ais far.I hereby certify that the well(s)was(.weir.)eonsrrnded in axordonce
7.isthis•arepairtoancxis6ng:wetl: Q3t'es or ONO "'!h'ISA'NCtCO2C.0I00orISANCACO2C.0200iFe!!
repai is a repair,f U om*Rown well contlrucrion information arrd o0�O•f4fs?�nfharbem pmvlded to-the yell owner. ��Irnclloh Slandarrls turd nc�l.a'
rrpairander 921 remanfa seetion or on thebaak ofilrr3 form. lO1n ore naturrojthr
:f— 23-Site'diagt-am or addifio11dwell details:
8•Number OF-11s.constructed: YOU tnl►I the biI of this pant to prOvidb additional well site details or well
For mukiple injection or non-water supply wells ONGYwtlh lhesmne eonsriacGarr you can construction details. You may nlso.attacti additional submitoneform. Pages.ifnecessa y.
j SUH1l3MAL IN$TUCTIONS
9_Total•we1I depth below land surface: / 6 D
Formult7ple weffs 11mall depda,fdoarent(ermnple-3Q200 and7( LM) (fry fo7idw
24a For Air Wets Submit this fonu within 30 days of completion of well
10.Static wafer level below top of rasing: construction
2 tbthe
Ifvnur level is above casing,use^+^/ OIL) Aivision t W9terQuality,Information Processing Unit,
M7 Mail Service Center,'Italeigb,NYC 27699-1617
eter:
11.Borehole diam d7 /
fin') 246.For Iniection.Wells: In addition to sending the form to the address in 24a
12.Welt construction method:. ac/ 4e eve,also shibrrrit a copy of this font!within 30 days of completion of well
(i.c avgtr,rotary.eabh:,d¢ect push,etc.) ---� cami titWon to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undetgionnd Injection Control Program,
1636 MAI Service Center,Raleigh,NC 27699-16m
I3a.Yield(gpm) Method oftest- 1316llvn20 minute 24r-For•'Water.Snouly&Iniectiolr wdis 'In addition to sending the form to
HT tire addresses)above,also submit one copy of this form within 30 days of
136.I)isinfcctioD type: Amount: V2 CUP �et opShu�1 construction to the c&uf health de
partment apartment of the county
Form OW-1
North Carolina Department OMv&Dnm^^t and Normal Resources-
Division of Wafer Quality
Revised Tan.2013