GW1-2022-10789_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Oniy:
I.Well Contractor Information:
:
.-WWATERZONE ,:"`s'4:w :''� .:Y.I :a �: '+' 't"•s�}::;r:•L 1:;: ":{
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DESCRnraC I i
WeUCoutractorName iG it 1
NCWeUContmetorCerttficatioaNumber 335SOli EMCASING tolrmnlficaledweUs ORZ]PIER Ea"'MEM
FROM TO DIAMETER T MKNESS MATERIAL
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CompanyName 416:II�iER'CASINiG ORTUBIPIG:'edNieemeli3med-loo MC?.,ai'•f riv fiT {J4".• ,
�� �) Q�� FROM -- TO DU1h1E1ER TMCKNESS MATERIAL2.Well Construction Permit#: n, tt m.
Lfstalt app0eable welt construction permits ge.v[G County.State Parlance,etc.)
ft
3.Well Use(checkwell use): �,. mow,, •:: x •�r3v ;s»�sI~,w u:is 3Str.';�.T3!
=17.SGREEN y
Water Supply well: -FROM TO DIA21>ETER .SLOrsmzWAV 7ffiC[avEsS MATERIAL
cultural MMunicipal1ftblic, 10 fe I it �•
Geothermal(HeatinglCooling Supply) Residential Water Supply(single) tt ft.
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InduskiaUCommercial �ResidentialWaterSupply(shared) yis GRoiITi 7�31;�x ;:?'rnrS�F: a`. '�ti�st ����
Irri ati0n FROM TO MATERIAL EMPLACE6fENTMErHOD&AMOUNT
Non-Water Supply Well: B
It to o ;
. Monitoring Recovery tG
Nectionwan: iG m
AquiferRecharge DGroundwaterRemediation g,1y;SArID/GRAVEI:PAGK d'a'"Ti@abte ;;s �;:vS.!• a�:=°k` 3 t, = 'n ut�';�`s
A Ulfer Storage and Recovery E38alhutyBarder FROM To MATERIAL EMPLACEMIMTMIEMOD
A IferTest OStormwiterDrainage �
ExpeementalTechriology nSubsidence Control it it
Geothermal(Closed Loop). E3Tlacer. 120.'DRII:LIl�iG LOG attsaliaddlH0oal3Txefs l[IIecnsa"
FROM TO DESCRU'llOtr eofaaLardans.sorifinek etel
Geothermal(HeatinglCaoling Retum) rJother(explain under#21 Remadrs) f. Et '
4.Date Well(s)Completed: I may—2 2 Wel1ID#
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5a.Well.Loeation:
a >:, JVA
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2C l� ft tt
FaaetlownerName Facility (ifappUcable) _
�y� �J ] y� • iG ft !
�(,�"r .•J f I d1)/ Ib ���,ro,vnale�n.�, - -
PhysioalAdd-,, .andZfp �7-�itY y�C ' ;2LcRIIt�tARICS�{3,:=v:::...,41.>:'Cslx:c.�:Za'.gt.aan t_IFYir"•�., .7�:%��x"7;rs'� +�;•
County UFa:eelIdentifieafionNo.(PII�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one btfloug is sufficient) 22.Certification:
Date
6.Is(are)the well(s)OVermment or Temporary
S eoE 'fiedWeilCoahaetor
By slgning this jornt,I hereby eer*that the I dIN tvas(vere)constructed In accordance
Yes or with ISANCACOZC.0100 cr 1SANCAC OZC.OZOO Vd1 Canfmc'1an Sraadards and that a
7.Is tbL4 s repair to an ex ng weil:
Ijehfs is a repair,jtfl out latorvn weft eoratrucKon injormafion and e�rpfaln the nature ojthe COPX°fd+�ncord has beenpravided to the well°Tuner.
reparrunder#2l reraarlsxeKon or on the backojthlsjorac 23.Site diagram or additional Well details:
8.For GeoprobelDPT or.Ciosed--Loop GeoWermal wells having the same. You may use the back of this page to provide additional well site details or well
c
construction detail&Youmayalsoattachadditionalpagesifnecessmy-
onstruction,only 1 OW-1 is needed.IndicateTOTALNUMBERofwells
drill ed SIIBMITPALINSTRUCPIONS
9.Total well depth below land surface: (ft) 24a.For All Wefts: Submit this fans within 30 days of completion of well
Fortiori/pleweltsthtalldepthrtfd(rerenr ftornplc-3@200'and2 100) constructioatolhefollowing• 1
10.Static water level below top ofeasing: �� (ib) Division of Water Resources,Information Processing Unit,
Ijwatertmellsa6avecarfn&uie 1617M UServiceCenter,RaIdA,NC276991617
11.Borehole diameter. 19 24b.For Infection Wells: Ia 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 construction method: 4044r y construction tollre following:
(ie auger.mtary.eabte.dhapuA.dr.)
Division of WaterResources,�UndergrouadInjection ControlProgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServIk a Center,Rdieigb,NC 27699=1636 _
13a.Yield(gpm) Method of test- I' 24e.For Water SunDly&7niection Wells: In addition to sending the form to
the address(es) above,also submit one'copy of this form within 30 days of
33b.Disinfection type: n-2- Amount: completion of'well constmction Ito the county health department of the county
s whereconstructeL I'
Fa=GW--1
iVorthCamlinaDepaztmentoEEnvironmentalQualily-DIvisionoEWaterRes lurcee Revised2-22-2016