GW1-2022-00027_Well Construction - GW1_20221219

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Pr1rit•Ftirm
\YELL CONSTRUCTION RECORD(QW-1) For Internal Use Only.
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1.1*11 Contractor hsfurmal(un:
LLOYD MARES IN.WATER ZONES
WellCounaclorName 1ROMt I To Imsr.ItirrroN
2547-A
n CNellConmaaCrnifearimt\umlei 13.OIrI'};H :1ti1NGrL nirnd OIEH�,a I
OrAa,AhTler nA.(for
mREGISTER WELL CO., INC FROM (Ta alAMuseartIMALr
Comluny Nmne
0 rL 275 IL 4 1n ,4 1PVC
PWS2021-1006$4 16.INNER CASING OR TUBING enth—atelan14.
2.1Yell Construction Pcrmit 0: RIMI To alAMM 131 T11H:HNISS MATF.nr.s+.
1.1 ofl opphro6h"wil eomrrrrcnen M-1,(I.e.VIC.C'nunnt Slurr 1 nnonee,ese.) !?. M In.
3.\felt Use(check we11 use): fL fL [a
Pater Supply 11'e11: 17.SCIIF.F.N
1lt0N1 Tn DLlM11.TT.R. c1A rcU.I. 7111CHNEM MIATXt1AL
Agricultural Q\tunicipal/Pubiic 275 0- 295 R 14 Ia .016 PVC
Gcothcrriul(Ilcating/CoolingSupply) )Itesidenlia WaicrSu 0ppty(single)
industriallcommercizl �RcsidcntialWatersapply(shared) Ia.CH.I I.. in
lai"Lion FT10t1 NArERtAI. i:gPL\fT\t�\T�+f:r11011&At10It\T
Non-Water Supply Well: 0 rL 20 rL HOLE PLUG POUR
Atonilorfng �Rccorrn' iL fL
Injection 11'ell:
A uifcr Rcchar c (L A.
q g ❑GrmmdnntcrRcmcdmtion
c
AquifcrStomgeandRccavery ❑SolinityUarrm I9.SANDIM- %XELP.ltaiifnli AWt FROM i To INtATtRiet. 13tP1-tO:NIG\TNIErl101)
Aquifer Test ©SIt1nn%witcrUrainagc 270 fL 295 A- 1#2 1GRAVEL
___ _ Fxprritpctltal Tcchnn�ngy___EISubsidenceControl— Q-_ O. __
GcoIhcimnl(Closed Loop) 2o.GRILLING LOG.(aRarh.ddirloeal,been Ifoece.,an '
I-IGM1110MISI(llealinalCoolrn Return) 17101her(eN lnin under 021 Remarks) Mult TD olScitivivS mis ..$—.wcle,x In.hr.rre.
0 fL 5 a SANDY CmLAY
a,Dntt%i'tll(s)Compleitll:S/31/22 . Well ID4 5 rL 11 R' CLAY
6a.Well Location: 11 fL 20 R• SAND COURSE
JOSHUA/NICOLE VINSON 20 n 28 <<• SAND CLAY LAYERS
Fociliq•�On•+rcrName rncihn•IDe(iratplkabk) 28 35 tL CLAY&SHELL
1912 WHICHARD CHERRY LANE 35 fL 45 to CLAY
Ph)TicalAdd,c,,,City.and Zip 45 fL 55 rl- CALY WITH SAND
PITT 21.L(FyI,tHICS
County Parcel ldemrlieaion No.(PIN)
Sb.Latitude and longitude in degrces/ndaultsfseeonds or decimal degrees;
(iraell fidd.—I'ACCOU..lGckat) 22.CerHReafianr
35.665293 N -77.258264
9120/22 ((`` (n�qq
6.is(are)thewell(s)a]st I-erwanent or 0"1'enlporary SlgiatarcorCau WellCaaractm pate D[l. 1 2l'L2
llpalgmnX dds frmc 16rreby sent&d w?114•uvlf(r)nvr(acre)cantrrurlal Lr arcnnsr+lce
7.Is(his a repair to an ezistingkitil; 13Yes or ENo n•1dr 15d,%rACO2C.0100,r15dhLS1C o2C.027111i0 G.o,nnacn,w GaJani„n„llh� Giil%?:e.'�'1 :^}r':�iR:�dft l� iS
Ord,"hnrpofr.fill our inm,n+.rllamnru.•nr+quf+nnorlMl-1 esrd nn nlnthe rereofthe copyofd ru dI lrcod ,been f—rded m rherrcllo+nrr. fi
rlarNd.' v1�
n1vir ander s21 renwrb rwrlon won sl•1Nx1 afdnn form Nd.
23.$ire dGTgram or add llional is ell de in Its;
S.For Ceoprobc/DPT or Closed-Loop GeoIherinaI\\'ells having dw same You may use the back of this page to provide additiorul twill site details or%tell
construction.only 1 GW-I is needed. Indicnic TU'TAI.NUMBER nftsclis construction derails.You mayalsoaltaeh additional pages if neccmTy.
drilled: SUBMITTAL IN517RII(MONS
9.Total well depth below land surface:295' (ft-) 24n. For All\1 elh: Submit this faun within 30 day I of completion of twit
Aw rnuflrpleve&1w alfdeprinf/Jf(crrnl(—plr-"L constnimion to Uk(ollouing: I
10.Smtic wRtrr level beleu top of easiag:32 (ft.) Ditifieu ofiVater Resources,Infornuliaa Proceming traii,
Junrerinrjunb,nrcmrn rue 1617AIall Service Center,Raleigh,NC27699-1617
I1.Roreholt diameter.6-3/4 ((,y) 2411;Fnr rilrclinp 1Yelrs: 16 addition to sending iiu form to the address in 24a
12,1\'ell canstruefion method: ROTARY above,also submit one copy of this form scilhin 30 days of completion or sell
(i.e.anger,retary.CAI..direct pudt ac.) construction to the follossing:
Divifinn oflYatcr Resources.Underi round Injection Control Program,
FOR 1VATF,R SUPPLY 11'E;LLS ONLY: 163611211 Service Center,Rnlrigh,NC 27699-1636
13a.Yirld(gpm)8 bktbod or test:AIR 24c.Fnr►Ynrer Snnniv R Inirrlinn Weil%: In addition to sending the fonn to
I311.pisinreelloa type:H7H 10 OZ tin:address(es)above•also submit one copy of this form ssithin 30 days of
Amount: completion of well construction to the county health department of the county
%vhcrc constructed.
Fmn Gsv-I Nortb Caroliai Depuoam ofEmitennrunrsl .1i Di,iiion orW.1 rResources
Q 0'- Itcviscd 2-22.2016
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