GW1-2022-10562_Well Construction - GW1_20221121

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informadow.
Talm✓, RIP � 14.WATER ZONES
Well Contta0w Name FROM TO DISC 01 TTION
ft. ft.W.H ,
NC� ,�J_. �c..s.& noaNumber 1.4.OUT MWING rmvin-casMWells RL iicat►le
i i 1 2-,Q 1 n r PR M TO fL I DIMIIiTER I EtCKNEft
Company Name 16.ROMCASING.ORTO MG dose"oo
2.Well Construction Permit A FROM I TO I DIAMEM I TMCitNM MATERIAL
List all applicable well construction permits(i e.UIC,Camay;Stale,varlaw.etc.) ft• in.
3.Well Use(check well on): ft. ft. in.
Waller Supply Wen: Vi SCREEN ETER LOT PROM TO DIAM SLAW TMCKNMM MATERIAL
Agricultural ON19affivaypublic O tt. ft. in.
GeothermalWater Supply(Heating/Cooling Supply) esidential Wa Supply(single)
Industrial/Commefaial E31kesidential Water Supply(shared) i&GROUT
Ini ation FROM TO MATERIAL METHOD de it�r1'AM01
Non-Water Supply Wen: ft• ft- r 1 r a
_ Recove Monitoring ry
Inection Well:
Aquifer Recharge 0Groun sArtn�dwaterlternastion DI ft.
19: cauvBc pAcx fa ltcable
Aquifer Storage and Recovery 13SalinityBanier FROM I TO I MATERIAL I E&Hq ACE flW METHOD
Aquifer Test OStor water Drainage ft• R•
Experimental TWhaoiogy 11Subsidence Control ft. it•
Geothermal(Closed Loop) DTracer 30.DRII.UJNG'LOG atfach additional dheetsif
Geothermal(Heat!W Conlin Return) [[. Other( lain under 021 Rcmarks 1 FROM ft. TO DRSCRiPnobi mlor,haWnemselftektim
1 ft.
4.Dade Well(s)Completed:1�=L-kwellID#
Sa.Well Locatlow. % t3, ft. .. ...p
A)WQ '),V rs ft. ft. "E r E 'i—
Facciiiity/(O�winerName I-,e�' Facility W9(if
Wlimblle) M ft. NOV 2 12022
C/ttN I r R"C4' 1 ,V. 0� fL ft.
1Lly
Pvo
cal dress.aty,and Zip ft. ft
r ly% 21.
County Parcel Identifies No.(M LLAs ev 6 t r.�f
c
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,oni�latllong is su<ficieat) 22.Certification:
6.Is(Are)the wells) ermanent or OT rerp S; of Co tified well Connector Date
By signing this form.I hereby at the wells)was(were)twwmcted to accordance
7.Is this a repair to an existing well: as or 0 tvtth 15ANCAC 02C A100 or I3ANCAC 02C MOD Well Construction Standards and thata
ff ihts is a repair,fill out larown well construaton lnjonrnarTon and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back offtform. 23.Site diagram or additional well detau'ls:
8.For Geoprobe/DPT or Closed-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 wells construction details..You may also attach additional pages if necessary.
drilled: VitRTrti7-i A7�rnrIIcrlotvc
9.Total wall depth below land surface: (R•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple veils 11st all depths Vdi8et+ent(example-3@200'and 2@100) construtction to ttte following
10.Static water level below top of casing: I 01L) Division of Water Resources,Information Processing Unit,
ff water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter:_ G /'f (in.) 24b.)E:ar Infection 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
12.Well contraction method: r /' I construction to the fallowing
(Le.- .mtiuXcabkd-apus,etc)
FOR WATER SUPPLY WE US ONLY: DJvidon of Water Rewurms,Undargmund bdectlon Control Program.
1636 Mail Service Center,Ralelgh,NC 27699-16M
13a.Yield(gpm) Method of test 24c.For Water SDDDIy&I'lligoon We11M In addition t0 sending the form to
the addresses) above, also submit one copy of this four within 30 days of
13b.Disinfection type: R I+ Amounts 0 U L- -_ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Favironmenini Quality-Division of Water Resources Ravised 2-22-2016