GW1-2022-09409_Well Construction - GW1_20221007

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'TELL CONSTRUCTION RECORD
This form canoe used for single or multiple wells For Internal Ilse ONLY:
L Well Contractor Information:
tA.YVKTER ZOAJES �
Well Contractor Name FROM TO DESCRIPTION
-337�- �lOft
_NC Well Coa S1drt 536ft ��� � 6 fs,o�Z a
tcactorCerc:C,carion Numlxr 15 Ot1TER.eA�1NG !ormolu-c&ftj,"is OR•LINEREfa Iicalile
82Mette Well ®rillong, FROM fill,
DL1ME1$t
Inca TR)CIWgSs MATFRiAL
Covrpaay Name in.
/ p ,Ib'INI�JCK.Ct►�SIN64t)1i•TUBING `mtlier" doted-l" (/
2.Well COnstmedon permit/i:_ / (I.I (R. ( 3 Z'J FROM TO DtAME1FR TttiCt4QESs MATERIAL
Lisp al/applicable u¢ll construction permits(r.e.Coanry,Stare,Varian,e1aJ ft is
I Well Use(check well use): ft is
Water Supply Well: ,lS::SG1t�EN:' '
OAgricullural FROM TO DIAME[ER SLOTSIZE THICRIVFM ifATERML
❑MrmicipaVPublic• ft ft is
❑Geothermal(HeatinglCooling Supply) G1Rnsidentia!Water Supply(single) ft. ft
is
❑Industrial/Commercial ❑Residential Water Supply(shared)
orni Ation FROM TO M1rersorer EMPLACPAtEKTMEfpOD'&AMO[1NT
Non-wawxbupply Well: ft ;?all�f
❑Monitoring ❑Recovery ft :Fa rt
Injection Well: R
❑Aquifer Recharge &
❑GmundwaterRenlediation I9'SAlY�lGR:4VI I;'PAL '"f'':fir stile
❑Aquifer Storage and Recover ❑Salinity Barrier TO MATERIAL ° t't ME.INF MEIHoll
❑Aquifer Test ❑ScormwaterDrainage ft fL
❑Experimental Technology ❑Subsidence Control ft rL
❑Geothermal(Closed Loop) ❑Tracer tl LiDiG'I;UG'Situ fi"A'di$o6iilntieets.ifneet sa
❑Geothermal(Heating/Cooling Return) ❑Other FROM TO DES(?tIPTJON wlor 6ardn soit/rock He
{explain under Remarks ft it
4.Date We11(s)Coutpletcd: ?2-7,Lg1e11ID# ll ��27 ft �' ft
52.Well Location: / & ft AJ
S •�!
Faei6ty/Clvvnerxaaie ft
/� Fadility 1D9(ifdppliabl6)
ft
}'
Physical Address,City,and Zip ft it
-
County ---may �81��s"3iz rS
PatcelldeaQfieaboaND.(PIN) f13:, ;,:,,�•,
A.Latitude and Longitude in d -
Of-ell field,one lard °unptesl5u°odsor decimal iiegrees: 22,Certiticatioa:
nag is safficiwr) "•'`-d:.✓` ,;+
&'Is fare),the well(s): [We—rroa ti of OTe hporary SsSaatiaeof.Ccnrfieil Well ContratAor Date
Bj.,signing A&farm,I hereby certify{hat the ivell(s)war(were)comtrucred in,awordanct
7.Is this.a.repair to an existing:weti: ❑Yes or e3w with•I5AWCAC 02C.0100 or ISA NCAC 02C_0200 W141 CO-Iiucdoh Brandon*mid thct o
'"1 is a repoir,fill out known well construction in ormaUan mid rOYo(this recordharbeal provided/a the w dl owner.
repoirrtnder�'2lremarkrsectionorontbebacko ihrsyorm. nthenatur 00e
f pt 23-Sit6 ifiagczn or additiorralwcn details:
8..Number Of-wells.constructed: ( You o trst the baclt of this pave to provide gdditiOQ well.Site details or well
For multiple injection or non-,varersvIr/rlywegs Ytrh iednstrucVon details. You may aiso.attach additional pages:if necessary..
submtroneform. ONLwrhesameconttrncf wn you can
�� SUBIHIXTALINSfUC7'IONS
9.Totat'well depth below land surface: 24a.Far A9I W.eILs: Submit this >Arm within 30
Formufriplewe/I,AW.11deprhsifdffieretit(dmnple-3Q200'andl 00 (;t) days of completion of well
QI ) constmetidn f6•the f01Idwing.
10.Static water level below top of casing: ( ) Division of Watcr uali Information Processing Unit,
Ifwnter/eve/is above casing,use"+" Q h+
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. fin) 24b.For Iuiect ilim.Wells: In Addition toisending the fonts to the address in 24a
p ���� above,also submit a copy of this form within 30 days of completion of well
11.Well construction restpomethod: /,-iQ R canstruddion to the following
(i c aoge.rdary.eabla,direct push ere.)
FOR WATER SUPPLY WELLS ONLY: Division of Water ltaleioh
Quality,Underground Injection Control Program,
+� 106 DWI Service Center, ,NC 27699-1636
I32 Yield(gpm) J Method oftest: Blown20 minute 24c I?orwater.Suooly&Iniecdo)t Wdlsl• In addition to sending the form to
1�TH 2 70 are addres
136.Disinfection type: ses)above,also submit one copy of this form Within 30 days of
Autom eofit'pletion of well construction to the county health department of the county
where eonstnu:ted.
Form GW-1
North Carolina Department ofFav:manrrat and Natural Resources-Division of Water Quality Revised Jan.2013