GW1-2021-03324_Well Construction - GW1_20210603

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WELL RECORD(M D For Internal Use Only.
I.WellCoutractorInformation:
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Company Name
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2.Weil Construction Permit#: FIRM To Tnl�/ay� — 3Hlf� RIATERIAL
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3.Well Use(check well use). R R i$
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triitmat Munita lIC ` FROM To Duras(6t-tFBi SLOrSEUE T MTER1AL
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Industrial/Commercial OResidential Water-Supply(shared) 18.GROiJT
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eRecovery or 3 Reil: RRt�ge [3Gra�dwaterRemediation19SANDICRAVEL PACKtorage and Recovery [3SalinityBarrier FROM To MAMMU L E rJlt EFer
est Stormz;aterDrsmae IL O� R i lt'oad Technology Subsidence Control R Ral(Closed Loop) 13Tratxd 20.Daa.MG LOG Mlwwn Aeeb Fal(Heaung7Cooiiag Return) Othef(e.�grlmn under#21 Remarl s t To nLscsll*liotvt�rrs�. rroa� �,esc)
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4.Date Weell(s)Completed: J v '� Well M# 1 ' t w ! $" R .rT AfJ SPPdlq (' i4
:59.Well Loeatiom R /D R TO-r; e G WU- 51 1 W
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Sk Latitude and longitude in hgrees/mivates/seconds or decimal degrees:
(sfwcH EmId.one tarlloag is s»ffician) 22.Certification:
35` 3$�,�0 1 N �o , oa3 1 9, W 0 c
6.Is(are)the well(SOPer t or 13Temporary Signatme ofCatified Well Comractor Date
BY sigirhrg dos form.1 hereby comfy that the mg(s)war(bare)consoeted in acrordmroe
7.IS k 13Yes or MNO wilh LfA NCAC 02C.0100 or ISANCAC 02C.0200 rereBConsa+utfmr Standards and that a
lfdris it a�}rair,frllmu Arwsr»rill cvrutrssctiorr itrj5ramtion Main the rename ofth, copy ofd&record has bempmv&W to the welt owner
repair mrder''21 remanb section or an the barkafddsfmm
23.5ite diagram or additional well details:
8.For Geoprobe/DP1'or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional sell site details or weil
construction,only I GW-I is needed. Indicate TOTAL NUMBER ofwells Construaron debark. You may also attach additional pages if necessary
dulled:
construction to the fo.l t
a t SUBMPITAL MSMUCTIONS
9 Total well depth below land surfing: } 24s.For All Wells Submit this,Forttmia�le,ceh&Ial de0tv''&fferetu(mm"ple-3@200-wd2(a)/(�'j ,owing:
his form within 30 days of completion of well
s
111:Static water hovel below
top oft ng: (It) Division ofwater Rtsa
7f�uterleael is abox omtn�ore"+" $� QEft
1 l 1617 Mail Service C�ter,ftaWigh,NC 27699-1617
11.Borehole diameter: (r1r.) 24b.For Iniection Wells: In addition to sending the farm to the address in 24a
12.Well construction method: Q above,also submit am copy of this form within 30 days of completion of well
u
(Le-aagc,ratmy.cable,dava paste,ems) construwon to the following:
Division of Water Resource ,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 106 Wag Service Center,Raleigh,NC 27699-1636
13a.Yield(ggm) Method of testi 24c.For Water Smolt&Weetiou'Wellx In addition to sanding the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type Amount: completion of well construction ter the carroty health department of the county
where construebuL
I
FormGW-1 NaafiC—b-IrspattoremofEavamtnmWQaeSty-DivisionofWaterR �
Reused 2 22 2016