GW1-2022-00254_Well Construction - GW1_20221222

I IIIR I VI
WELL CONSTRUCTION RECORD (GW-D For Internal Use Only--
1.Well Contractoelnformation:
,y//'1 L_.A C i�1614 : 14.WATER ZONES
Well ConnactorName ➢ROM TO u1scuppIION '
& C� et
NC Well Contractor CertificationNuodm[
R F monNaaoa Oat ranER re If®Die)
PROM TO niAalSfER TMl7Qi&4a btATEBiAI,
Company Name
34INNIDtCASING ORTTIRING(eofhmmel doled4w
2,Well Construction Permit I r PROM ro ntAMEt'ER Tmt70� MATENAL
List all applicable well constructionperuda(Le.U) Coumy.Stme.Yartance,etc.) ft. R is
3.Well Use(check well me): ft ft. In.
Water Supply Well: 17.SCREM
PROM To dmg I RLOTSUE THiC®'7PS4 MATERIAL
Agriculture! E)Municipal/Public O ft tt in.
Geotheanat(Heating/Cooling Supply) 016den[ial Water Supply(single) n
IndustriaUCommercial E31esidential Water Supply(shared) 18lRtOVf
Irrigation - FROM I To I REATMAL I 7 ISLA M6FEWDa:AMoaNr
Naa•Water Supply Well -
-.. Monitoring Recovery R .S3 ft.
If jection Well:
ft. IL
AquilerRecharge E3GruundwatcrRemediation M SANDIGRAYM PACK d' treble
Aquifer Storage and Recovery }Salinity Banter FROM To nrATr:xw, misl.Acrt'Msraoa
Aquifer Test MStormwater Drainage ft. ft. -
Experimental Technology E3Subsidence Control ft_ fG
Geothermal(Closed Loop) Tracer 20.ORII.LING L.OGanaeh additional sheets if necessary)
Geothermal(Heating/Cooliv Remelt) nOther(explain under#21 Remarks FROM To nPSCRIPTION(mlvr.LuNnm,soiPrvdc a.�r.eel
- ft. ,
4.Date Well(s)Completed: 47 -3 - 2=Wen m# 7•S• Y'44- Z ti
Sa.Well Locations ft' N•
A 3991322� Z3 7 ft tt - ; � �-•ct r
Famlity/Ownei-Name Faol Macisfappliable)
ft. It. J
Ria
aYL- L k .J- L.^r>j r /erif .re•L. • flit _
to
Physica Jl Addries,CSty,and Vis z'7 Z5'_ It. ^n F.�:-ySaits9
t 4r
Cauaty Parcel IdentSation No.(P"
56.Latitude and longitude iv degrees/minv[eslsernvds or decimal degrees:
e
(ifwell field,we tainting is suHiciem) 22.CmtiBcation:
6.1s(are)the well(s)Wermanent or OTemporary 14TpmWefCettifieti el( o or Date
By signing this form,1 hereby aatlh thm the wills)roar(woe)constracled in occordonce
7.Is fhls a repair to an existing well: []Yes or �o whh 15A NCAC 02C I1100 or ISA NCAC 02C.0200 Well Construction Standards and rho a
lf this Isa repair,jlllow known weil cownuction information and explain the nave ofdm copy of this record has bemprovided to the welt mvier.
repair under$21 remarks section or on the back of thisform.
23.Site diagrams or additional well details:
B.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 OW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary-
drilled: SUBMITTAL IlVSI'RIICTIONS
9.Total wen depth below land surface, L'.G= (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
Formultipte welts tlstmldepths ifdlfjerent(exampk-3(�2�and7(j100) construction to the following:.
10.Static water level below cop of casing: 1 s (ft) Division of Water Resources,Information Prvicesshrg Unit,
IfuWa level is above casing,use"_"1- 1617 Mall Service Center,Raleigh,NC 2709-1617
11.11orehole diameter: L.: ' (in.) 24b.For Iniection Well a: in addition to sending the form to the address in 24a
L above,also submit one copy of this form within 30 days of completion of well
12.Well consbaction method: ►` 1� construction to the following
fr-d auger,romtY,able,direct post,ate) -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mad Service Center,Raleigh;NC 27699-1636
13a.Yield(gpm) 1 15, Method of test: Z4%For Water Suanly&)(.action Wells: In addition to sending the form to
the addresses) above, also submit one copy of this fora within 30 days of
MIllsinfection type:�/ T H Aumonk. gew t. e Q completion of well construction to the county health department of the county
wham constructed -
Fan GW-I North Caol®aDepamnientofEmdroamenmt Quality-Divisionof Wear Resources Raised 2-22-2016