GW1-2022-09482_Well Construction - GW1_20221014

- "ONSTRUCTION RECORD fGW-1) For Internal Use Only:
.:ontractpr Information:
JPrr 1; r,�*QcdA 14.WATER ZONES
Well Conhaoms Name - BROM TO nasCauTjft--..1
I�S1� R R
R R
NC Wet Contractor Cestifioeti-N®hc
76.OUTER CASINGformdfiaard gm=R ids Rcahk
YADIGN WELL COMPANY,INC. ;q� FROM To nwsrmMMS MATERIAL
R Company NemeI6.1NN1tR CASING OR Tf181NG d-loo7-WellconstructionPermit#: 7Gy FROM To nustrre 1MOOS MATml7AL
List all applicable well consbanlon permits fie.LAC,Coumy,State,Yarimce,mic) R y 3 R L � R l Ps1G
3.Well Use(cheekwtH use): - R R f
Water Supply well. 77.tgCREEN
FROM To DrAsnrrRR s1.OT Z
vess MATeRrAI:
(]Agimltora] OMLmicipeVPublic R.
OOcothermal(Ileetmg/Cooling Supply) f7Residential Water Supply(single) R
Olndustrial/Contramnial �identisl Water Supply(shared) 18.GROUT
l7lni 'm OWells>10(1,000GPD mom 2O MATERIAL rMetsoaAAMovNr
Non--Water Supply Well: ft. a R P'Ir ,
OMmtmrmg OReaovery R R Me
Injection well:
(]Aquifer Recharge OGramdweirr Remediation R' R
da linhle
l7Agldfer Storage and Recovery OSelm 19.SA1VDIGRAVF.L PACKity Barrier FROM To MAtsRtAt EMPI.AC�NTMSfHOD
OAquifer Test 08torm ge water Drama R R
OExpvmmeatal Technology OSubsidence Control R R
O('ieoth®el(Closed Loop) 0Tracel' 20.DI2IISSNG LOG attach additional sheets ifnecasa
OOeothermal eating/Coolmg Relmn) 001her( lain under#21 Remora) FROM TO QnP col DFSTION or,h soN sue,eon
IL Pk&
4.Date Wa(s)Completed: 562R 12 gg R !MIL a
5a.Well Location: Phone # �{�5�033 ft. R
�¢�>Zcr Fre�t��i.t�l(ei' oiler �pf'Fw '� R
Fe©'ti/ty/OwJJnerNema/' P�dryplieable) R R
firtf;yr- ft. R
PLymnalAddress,City.and Zip y R R .
T^ S./L//L 21.ngMARKS
Conoty Parcel ldeoti5ce4oallo.(Plti)
5b.Latitude and longitude in degrees/mfnutes/seconds or decimal degrees:
(ffwa fwId,one lat/long is sufliocut) _ 22.Certification:
'3` I;C q2 .0a N 91 31 p W
a
6.Is(src)the well(s): Oermanent or OTemporary Siguatot of C4ffied Wall Ccntmtcr Don ,
Byslgningthirform,]hereby eertdylhal the well(j)was(we")can cfadrn accoMmsewifh
7.Is this a repair to an existing well: 0Yes or J(No 15ANCAC 02C.0100 or 15A NCdC 02C.0200 Well Consnadion amrdards and that a ropy
]ffhtr is a mpair,fell oul known well construction bTfarmatlon and esplaut the mm=of the offhit recordhas bean provided to the well owner.
repab•msder 621 remarks section or on the back ofthi form. 23.Site diagram or additional well details: _
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 OW-1 is needed. Tadicste TOTAL NUMBER of wells (add'See Over in Remarks Bar).You may also attach additional pages if necessary.
drilled: .1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /0S3 A)
For multiple wells list all depths/fdifferanl femmplo-3(a)200'Md2®100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of caring:_ NIA ( ) �• For All Wells: Original form to Division of Water Resources (DWR),
jfwmer level Is above can)rg,use"+" t Info bm Pramessing Unit,1617 MSC,Raleigb,NC 27699-1617
11.Borehole diameter: _({a.) Bit Off:4WD Js439 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
(Lc.auger,rotary,cable,diraot path,eta.)
24c.For Water Sopply and Open-Loon Geothermal Return Wells;Copy to the
courrty envuonmental health department of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water(gP ) Wells producingover 100.000 GPD: Copy to DWR,CCPCUA
13e.Yield m Method of test: �+/b1� P= gmrq 111 MSC,Raleigh,NC 27699-I611
- t,� ssttyy Q M '
13b.Disinfection type: 70%HTH Amount: OZ DATE E VISITED7''!7'�Z
Pri r•P• VISITED BY: '145