GW1-2022-10518_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD(GW 11 For Intemal Use Only:
1.Well Contractor Information: r
WellCoenactorName FROM TO DFBCRIFITON
aogS -A ffi
ft. ft
NC Weil C MImetar Ce n Namb�\
1 1 1 r IBM TO DIAMETER MCMISS MATER AL
company Nome hL
2.Well Construction Permit#• a`O a a O a FROM TO DIAMETER THICInVF88 MATEMUL
List aU applicable well conrinredon permits(Le.MC,County,State,Variance,eta) ft. M in.
3.Well Use(check well use): IL in.
Wirer Supply wen: FROM TO DIAMETER SLOT SEM THICK NHSS MATERIAL
Agricultural 13m blic & 8 I In.
Geothermal(Hcating/Cooling Supply) teal Water Supply(akgie) ft. tt. in.
lndustriecommercial Residential water Supply(shared)
h77 'pp FROM TO MATBRiAL MOLACEM M MBTHOD&AMOUNT
Non-water Sup*wen:
Monitoring Recovery ft. ft.
Injection Well: ft. M
Aquifer Recharge DCaoundwater Remediation
` Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft M
Aquifer Test 13Stormwater Drainage
Experimental Technology 13Subsidence Control & ft•
Geothermal(Closed hoop) Tracer
FROM TO N serer huda eaatreek ate.
Geothermal Coo Return Otber lain under#21 Remadrs !ti ft. Q T
4.Date wells)Completed: Well IDfI tw p tw A(� R rq aJ � {
53.Wen Location:( .s.
h nr. ft. ram,C _ i
Facility/ Name Fw ity EM(if applicable) fL ft.
n ft.
NOV 2
Ptrys' ,City,aadZap & ft. irgoana+ -ln ;']t. a3gtg Urfa
d 7A, Co ,
County Parcel Identificatiion No.(PIN) }
5b.Latkode and longitude In degremkolautealseconds or decimal degrees:
(if wcU field,one lat/long is sum) 22.C n: n
O 3-1' $ / N q A b 4 O W
6.b(are)the wen(s)�t or DTemporary s nature ofCertiSed Well Contractor Date
— By Aping this form,I hereby certify that the xeU(s)rHus(were)conrtructed in areordmrce
7.Is this a repair to an existing well: [3Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Conmuedon Standmdr and that a
Ifthls is a Fg 'fell Ord brown well oweducdon it formation and er<platn the rronae of the copy of thin record has been provided to the well owner.
repair corder#21 remamb section or on the boat of dusform
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Clon&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 GrW-I is needed. Indicate TOTAL NUMBER of we construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: UL) 24a. For An Wells: Submit this form within 30 days of completion of well
For multiple wells lint aU depths(rdVffew(esarnple-3@200'and 2@1001 construction to the following.
10.Static water level below top of cuing: (fL) Division of Water Resources,Information Processing Unit,
If veneer level is above cwft use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (>n•) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of complexion of well
12.Wen construction method: o��r construction to the following.
(Le.suety rotary,cable,dhect Push,etc) 1
Division of Water Rewurees,Underground Injection Control Program,
FOR WATER SUPPLY WELiiSI ONLY: 1636 Man Service Cerrter,Raleigh,NC 27699-1636
13a.Yield(gpm) O `!!' Method of tat: r 24c.For Water Supply&InfectionWells: In addition to sending the form to
the addras(es) above, also submit one copy of this.fora within 30 days of
13b.Disinfection type: Amount. �� - completion of well construction to the county health department of the county
when constructed.
Farm GW-1 Norte Carolina Departawnt of Environmental Quality-Division of Water Resources Revised 2-22-2016