GW1-2022-09916_Well Construction - GW1_20221031

WELL CONSTRUMON RECOI v(GW Il For Internal Use only
L Well Contractor Information: "
ken tAAr .14.WwrERzort$s....
WenCoonactarName FROM TO DESCRII'rlpH
.20o R 2,70 ft
R R
NC Well Can oar CatiScdion Number 1,M.OUM CAMG foutmuld e d iw1j a OR L1Nlt1t
�e mtalrl 1 FROM TO DUMEM MA :17AiA1.^'tl Viers 1riYc . R fn
�S.J �7 i16' CAMGOR ,.dr G . . *fi1V M6sid too 2.wen C Mft tion Permit#: FROK To Dlanizrm i TMCKNMsrATaerer,
UsraUappBaab/e+ Qaiatrne8a»permNs(t a WC Cozvz%Stam varfmx%ere) ft ft &� ,
3.Well Use(check wen use): $ R t is
i
Water SupplyWeD: s}17SG'[ts�Tr' •;' ys':Jr'' a.4T',:.rrA,�k�Ca:,t., i r�;:.r...�rt f:s,, _.
FROM TO --Fn—m—mr—r--F--Ayram • THIS IMATBRW,
OAgdcukural ❑Municipal/PubUc R R m
❑Geothermal(HeatinB/CoolmB Supply) OResidential water supply(single) R R sn
❑IndushiaUCommerciai Wtesidential Water Supply(shared) y
Omgatiop ❑Wells>100000GPD FROM To MATtRML 9&UtMtNTmmmoDAAmouw
Non-water Supply WetL• D .R -24 ft /1�etl
❑Monitoring ❑Recovery R R
Injection Well:
❑Aquiferltecharp 13GaoumdwdberRemediation R R
A9uifis .49.SAND/GRAY PAC&d ::� "�7:=v sF' •. rya ."ems T:cE t.^.,.
❑ S and gSalmilyBarrier FROM TO MATERIAL. ZMPLACRItrII�rrD�9D
❑AquiSerTest ❑StormwaterDtainap ft ft
❑Bmgnaimental Technology ❑Subsidence Control R R
❑Geothemmel(Closed Loop) ❑Tracer -20.DRIi.LIl�iGLOG alfieL'ilddltiadoiil 1iFE6 if'" '`
OCva%emmal esting/Cooiurg Return QOdux(explain under#21 Remarlrs) FROM TO Dffir�IION cote •�iihaek ;.;.de :"
R R
4.Date Welt(s)Completed: Wen W#_35`S44A R &
5a.Well Lofadon: ' R tt n;a
Cr�re Crol�s,r; R R ,.,
FAYJgwzwrNa= Fac tyM6(ifappliable) R Ron 3 1 2022
3+x $rush, O re e k Road =5 w ,V C R
t�ttyc,ndz;p a�G 7� R R 1rh5 NOVO
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rtl eq k „ucotaily
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PamelMentifiamionNo.(P"
5b.Latitude and longitude in degrea/minutes/seconds or decimal degrees:
of-an fief 22.Certification:
3Ls°r2(o '1•�. N l 0 34 It .
F- e �243a�
6.Is(ate)the well(s): ❑Permanent 'or ❑Temporary S Dace
BYsfg dd*form lherrbyee{rlfyrha dwweU(S)was(w M)cwvvumedbiooeo dm wwrYh
7.Is this a repair to an emdsting well:- •QYes or MNo ISAIVCAC 02C:0100 or 15ANCAC 02C.0200 Wes Consnmedm Stmidw*m,d dmr a copy
jfthtr tr o npcfr,ftU ortbaewa well Qarrrbtnaeon trg6rmmrtorr and ar&ft the ranee ofrhe of this raoard hay bevy prwfded ro the w X owner.
'rqufr aril #21 reinarksecoon or on fheb=kOf*$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 eonsirurcdm info
constnrclim only 1 GW 1 is-needed.Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box}You may also attach additional pages if necessary.
dulled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For muldpk welly 1W all depde ff (aoo Vk-3@200'amdd2gt00) (ft . Submit tMs GW 1 within 30 days of well completion per the following•.
10.Static water level below top of easing•. *0 24s. For-All Wells: Original form to'Division of Water Resources (DWR),
lfwumrlewd tr atSovs aarbr�jve~+- hrformation PmCessing U k 1617 MSC,Raleigh,NC 27699-1617
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1L Borehole diameter..
_ •Cm.) 246.For Injection Wel)x Copy to DWR,Vndeugroumd Injection Control(IUC)
Progimn,1636 MSC,Raleigb,.NC 27699-1636
12 Well construction method: r01�►rt-1 a 1 r -
Cm mqK„��1a Apo�) 24c,For Water r SuDDIv and Open-Loon Geothermal Retina Wells-COpy to the
coumry environme�l health department i county where insmll'ed
FOR WATER SUPPLY WF,I;LS ONLY: 24d.For Water Wells Droducinp over 100 00 GPD:Copy tu.DWR,CCPC(JA
13a.Yield(gpm) 3 D Method of teak QL 1 r Permit��1611 MSC, C 11 u
13b.Disinfection type: [+n-f- Amount:
Fore,GW-1 Nmtb Carolina Delmbu=ofEnvironmwoml Quality-Dirmon of Water Resoarees Revised 6.6-2018
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