GW1-2022-10517_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only.
1.Well Contractor Information:
Well Contractor Naar FROM TO D CRH IiON
10 & Ili % Ce- - Z
fc rc
NC Well Contractor Certification Number 1
,IaP� C��.'I we�1 �� \i ► rC FROM_ TO D TH[eaavess MATERIAL
Company Name
o �- q K � 4
2.Well Construction Permit#: a 0 a a ` 00 `�`� FROM To DIAMVIXR THICENM MATERIAL
List aU applicable well conshucdon pemti&(te.WC,County,Staff Vanance,etc.) tti % hL
3.Well Use(check well use): �' ft' is
l.iMEr
upply Weil: FROM TO MAMETER SLOT SIB THICENESS MATERIALltural DMusicipalMublic % ft.mral(Heatmg/Cooling Supply) C)Residential Water Supply(�Sle) ft. it. hL
Commercial Residential Water supply(shared)
FROM TO MATERIAL CELYffiV'f METHOD A AMOUNT Supply wen: & oa'tt & CO&UeT 1 t) b �,
nitorin _ _.-- Recovery fL ft. •Intion Well:
Aquifer Recharge �Groumdwatei Remediation
` Storage and Recovery DSallnity Hamer FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStomiwater Drainage
EVerimemtal Technology 13Subsideow Control ft. tL
Geothermal(Closed Loop) 13Tram
FROM TO DFS ON eobr 6uda so /raek etc
Geothermal Coo Return Otber lain under#21 Remarks
4.Date well(s)Completed: °I 1 Well ID# 3 �''a Z 0 %
So.Well Location: ga fL mN- 2
4 (-C+) N � ��s a 3n ft.
Facility/Owner Name FacrMWW#(ifapplicable) % %
�► `� PAY., 0 6� P z�.e.�r; I Ve , C'3 C R IL
Physical Address,City.and Zip
R6al, 3g (AS 4-ID o
County Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: �,
V 2 1 202Z
(dwell field,one Ist7ong is sufficient)i 22.Cerdfle otion:
i
�so 3 a 1 3 ?' N g a ° 37 ' �'' W {n; o a .�
.�� as
6.Is(are)the welt(a) ermanent or Temporary Siguatum of Certified Well Contractor Date
By signin8 this form.I hereby c&*that the w fl(s)was(were)consbvcted in accordance
7.Is thisa repair to an existing well: C)Yes or LjNo with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Weft Conmucdon Standards and that a
!Rhin is a relmv,frll oat brown weg cony& cdon hifornwdon and exploit the native ofAe copy ofdas rwmd has been provided to the well ownff.
rgWr wider#21 romans sechm or on the back ofdurform
23.Site diagram or additional well details:
&For Geoprobe/DPT or Clow&Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wellslon details. You may also attach additional pages if necessary
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below bud surface: (ft) 24a,For Ail Wens: Submit this form within 30 days of completion of well
For multiple welt list aU depths(ld(f row(example-3@200 and 2@1M construction to the following:
10.Static water level below top of cuing: (It.) Division of water Resources,Information Processing Unit, '
Ifwnaff level is above aarft are"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter. (In.) 24b.EQr Infectlon wells: In addition to sending the form to the address in 24a
above,also submit one copy of this;form within 30 days of completion of well
IL Well construction method: construction to the following
(Le.anger,rotary,cable,direct posh,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY ONLY: 1636 Mail Service Cen�ter,Raleigh,NC 27699-1636
13a.Yield(gpm) °� Method of test: �"t 24c.For Water Sough&Inieetiort Wells: In addition to sending the form to
the address(es) above, also submit one copy of this.form within 30 days of
13b.Disinfection type: T`Z Amount: �O 6 L completion of well construction to the county health department of the county
whero constructed.
f
Form GW-1 North Camlma Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016