GW1-2022-09400_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
L WPM Contractor Information: f
ta.WrSTER zoriEs �
Well Contractor Name __ FROM To DESCtti moil
/tom Iz_& Z ,ds
NC Well Contractor Certification Numhcr �S�f t 6 ft (�[ g /'r Z 2 �'� zi��
Well
i •dUTBR.F'451KG for multi-cased0� �vdJs OR-11NER'1f a licible• `/�,```�
82MOtte ell D rillingy Inc. FROM fit TO DL1ME1'Flt TH1Cr4VE5S MATF1tiAL
ft. 5�1. ( G
Company Name fLz�`
/� Z . •.rs'1t�11 K,G�1,'SIit1G•olt•3'OBING.`e it}ieirunaleloied4_' ..
2.Well Construction permii#:_ //, 7 3 RRam TO DUMETTFB TFi[C[INPSS MATEBietL
List all applicable t+rli consauction perrmts(t e.Ummty,Stale,lrarionce,ejq f t is
3.Well Use(check well use): ft tt in.
Water Supply Well: 1' SCRZ EN:
FROM TO D1AM6IER❑ SLOTS= TBICKNFSS t1tATSRUL
❑Municipai/Public- ft it in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) :]8iGltllllT .'_ .
Ckrij.Ration FROM TO htaTtRr•r pryrPUC�iF�.rMEIFOD&AMODNi
Non-WaterSupplyWell: D ft �6 ft 2and/ oY
ment
❑Monitoring ❑Recovery fit ft
injection We11':
' ft fit
❑Aquifer Recharge ❑Groundwater Re.Mediatinn 19t'S91YlY/G12'A"ttEL PAVR f':tiCotile
❑Aquifer Storage and Recovery ❑Salinity Barrier At To MATPRiAL �eLtCehtEari MerHOD
❑AquiA:rTest OScormwaterDrainage It fc
OExperimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer :'2tl1? Lit+t '1;UG:aita+Cr. dtliiivaiif�$eefsiftf '
❑Geothermal(Heating/Cooling Relum) ❑Otha - FROM TO DESQtIpf1ON Wier hudn
(Main under#21 Rematks (� ft
4.Date We(14)Completed Z9-ZZWeI['WN Z' fL ft r2 0 et gdV S
Sa./Well Location: 60 ft SO t-,C
—� �f ft Z60ft G
Fanhty/Qn.rNamc & ft
�J w -n Facility Mp(ifapplieablb)
iL
PLysicat�ddmss,City,and Zip ft ft
d'JP12-a�D�✓ Z OZZ
(per County Um,parcel id eotificaboo'Nn
Sb.Latitude and Longitude in degrees/minptestsewhdsor decimal i)egrced:(ifwell field,one ladlong is sa(ficient) 22.Certification:
36- N f# : �1�-'rT w ��c;►�•t.r.�� �', P..� � . -� l—z.Z
6:'1sf9re):tbewe1l(s): t. oe OTebpotaty S'stofceffifie4areIlCoutmftr Date
AY,si&1ngAJs farm,I hereby certify tlwt the'waft(S)wtm(were)constructed in aecordance
7.Is this-a repair to aim existing;weU: ❑Yes or CKu_ with l3A•htCtC 02C.0d00 or ISA NCAC 02C.0200 Well Conairrtction SYandatrls tail thcf o
Ifthis is a repair,fill out known well eonsimclion information und. QOPJ'Ofdtk!ecordharbeen pmvlded to the Well owner.
rcjmirvmkr f2l remarkr section or on fhebnck o ihls orm. n the nature ofihe
f• f 23.Si16 d'iagftm or additiorialwell details:
8.,Number ofweUs.constructed: You mtry us6 the back of this page to provide additional well,site details or well
For maltfple injection or nan-lratersupaly wells L LYwit6 rbesartre eonstrttoGan you can
b6n��on details. You may g1so.attaeh additional pages:if necessary.
submftoneform. S1 0MMALINSTUCTlONS
9.Total'wdl depth below land surface: 6® (ft} 24a. For Ail wells Submit this form within 30
For mrdrip/a wells list aIt depths if diffemf(emmpit-3Qa 200 aand2 00 days of completion of well
1 Wnsduetido tothe following.
10.Static water level below top of casing: ��. (ft) Division of WaterQuality,Inibrmatiou Processing Unit,
Ifwater level is above casing,use"+/" 161711'fatl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (ia) 24b,For Iniecoion.Welk: rn addition toi schding the form to the address in 24a
r1 above,also Submit a copy of this form 2v withim 30 days of completion of well
12.Well construction method:_!? (� r� conshuttiontothefollowing
(t.e.auge.tot=y.cable,detect pusk Ue.j
FOR WATER SUPPLY WELLS ONLY: Divisiod of Water Quality,Underground Injection Control Program,
106 Mail Service Center,Raletoh,NC 27699-1636
132.Yield(gpm)_ z�b�Method oftest: 8111own20 Minutes 24t FotiVatct.Smolily&Iniectioh Wells- In addition to sending the.form to
�'-� � r�- tiro address(es)above,also Submit one copy of this foim within 30 days of
136 Disinfection type Ilmo>m� cohipietion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina D epattoreat ofF.mrirawneat and Naomi Resouttes-Division of Water Quality Revised Jan.2013