GW1-2022-09408_Well Construction - GW1_20221007

WELL C0N.RTR1r7CTI9_%PT REC(DRD
This torte can be aced for single or multiple wells For internal Use ONLY:
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1.Well entractor Information:
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y e FROM TO
WeU Conhactor Name _ DEStatrT101V
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NC Well ConftetorCerti6eacioaNambcr 16.Ot1TER.EeISO+TG forfird �'.�vel(5 ORI.IDIER`tfa lfrstite ..
13a2MGttG Well Drilling, Inc.' FROM � m DL1MEfIIt h rtucravess MArF1trAL
ft
Cow taayName se)A�L Al,
..T6�N. IC:Cr1SI[+10.012'WBING 'Hi
I '' FROM To ertual.elLLied-3"
2.Welt Construction Permit#- W Z� '®' ,�J � DIAMECFA •rH[C[�pfig 7yArp�L
List al/applleable xrll construction permits fix,Cmmry,State Irariance,etc.J � � is
3.Well Use(check well use): ft in
Water Supply Well: .'1S::SClt3:EN:' .
FROM TO DIAMETER SI,OTfiIZE rtilC[OVESS OAgricultural ❑Municipal/Public• !t fL in. htATERtAy
OGeothtxmal(Reahng/COolingSupply) �idential Water Supply(sin&) tt ft in.
❑Industrial/Commercial OResidential Water Supply(sh�d) :1s c.�tQUT
Olrri ation FROM TO MATERIAL EMPLACEMEM ME[FOD'&AMOONT
Non.Water Supply Well: ft ft t our
OMonitoring ORecovery ft 34111
Injection Wcll:
fL R
OAquiferRecharge ❑Gmundwater;Rerriediation SAlYp/ iq,YPL'PACTC t '°Uttile
❑Aquifer Storage andRecovern ❑Salinity Barrier FROM ro niA17?RtAL EMplwceitiavr.htenaoD
❑Aquifer Test OStomtwaterDiaitrage ft ft
Ofixperimenta[Technology ❑Subsidence Control ft ft
OGeothetmal(Closed Loop) OTmeer '2�«I? I,1I+IG'LOGG'sifailli.drlibiln eT.3 eels i f
❑ycothe[ma( FROM TO DESatIPTJON eolor 6ardn soil/trock(Ileating/Cooling Rehlm) gOther(explain under#2I Remarks ft d- ft
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4.Date Wells)Completed: Q-Z7:1&Well'ID# LlJZ1 l R L 3 ft �r
vie �o
Sa.Well Location:
6A etaN K® rn� S ft 7- 6 RP a
FaeiUty/0w=Name ft ft
Faci[itylDp,(if appIieablej
�• ft
Physical�Addre iii City,and Zip
ft tt
County Parcel ldeog5cartotrNo.(PIN) - - -
56.Latitude and Longitude in degmWinjuptes/secondsor decimal i)'
f5Certification-
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(INvell field,one lallong is sacient) 22.
`P N r
' 2
6:1s are'the wills §ri;oauu`e0fCct1Tw4Well'Coutrattor Date
().-�e+cfmanent, or OTemporary
By atgrrtngAfS farm,I hereby certify that the I-well(s)was(were)constructed in aceordance
T_TS this.a.repair to an cxistin well: OYes or [bAlo- wltb I3.t AU4C 02C.0100 or ISANCAC 02G.0200 Wdl Constivedorr StondanCt aird theta•
If this is a repair,fill out-Imown well consdaction information 401d d plain the nature-or-the �--rd harbeen proWded la the salt owner.
repair+mder f2!retnarkr section or on tbabackof ihlsform. 23.Sitb'dlsgism Or ildditioltSl Well details:
Number of wells constructed:
You m die back of this page to Mv.idc additional well,site details or well
For multiple injection 0eection ornon-warersupply weAs ONLYwirh the some cotubackorr— B c �ion dnstrucay nsb details. You i ii 81so.attach additional
F you can paDes if necessary,
submitoneform.
�.7 SUOMMALD(STUCTIONS
9.Total'well depth below land surface:
Formrtrrple wefts listalldepdatifdrffererit(ezample-3Q200'and2 O0 qL) 24a. For AI[We1L� Submit this form 41hin 30 days of completion of well
QI Wr shudfdn th-the f011dWiitg:
10.Static water level below top of casing: ( ) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use^+^ 1:617 Mail Service.Center,Ruleigb,NC 27699-1617
11.Borehole diameter. n (�) 246_Far IDIee on.Vllells: In addition to sendinE the form to the address in 24a
12.Well construction method: II (�- &1� eve.,also submit a copy of this form within 30 days of completion of well
(t.e.et{gc,tptary.cable,dinxt push,etc.)
constr nation to the following
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gP )m Method oftest B'own20 minutes 24C lFoIrWa Bttet.Sunuly Iniectiolt Wet .form ls:'In addition to sending the to
13b.Disinfection HTH 702 the addr=(es)above,also Submit one 1copy of this form within 30 days of
type: Amount coinpietion of well construction to the county health department of the county
where constructed.
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Form GW-I North Camlim DeP'sh cot of Eavimamcat and Naaual Resoumes—Division of Water l2uetity Revised Jan.2013