GW1-2021-07818_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD rGW-1) Foriatemal use WT
I.WescoldraclorbalIKINNOW
Daniel C VeM r.,
WellCouftactorName p r FROM TO I DPSCRUFT ON
NCWC 4368 A
n. ft.
RC WcF1— Numba
r` � � ,
Maupin well drilling LC �I �, •3 rc(;',Z 'FROM TO MAMLMM TciBS3 MATERIAL
fit-, 1 D- 24 fL t IM I-L IdMO pvc
COMPMY viarm `�,�
I wen CoosbrnttioD Permit#: :; C FROM TO I DIAtEffit I IRK30MS I MATERIAL
140agappficableneHamaaactionpenrrils(r.e.c7ce ?'S +.mranoe7 uc) $ ft. ts.
1 weft Use(ett.rdl os4- D & Fn
Water Supply well: 17='S >3F1'►:,;. r "';
FROM I TO I DIAMSIFdt SLOTS= I TMICKNM
..MATERIAL
L-..E
13MuniGFal/Publi. 24 fL 34 1L 1114 to OA10 sog40 pvc(Heat�Caoling Sttpply) OResid-tial Water Supply(single) 'Lmnmereial Residential Water Supply(shared) FROM TO MATERIAL ffiNMdILIIIiaR'MErHOD&AMOUNT
Non-WaterSappty Well: 1 D• 24 D• �pqy graft
Monitoring Reoovay tL tt
Injection Well:
tt D.
uifet Recharge pElGroundwater Remediari� f94:5A1NDv+C At i:PAGK
L
rage and Recovery OSasnity Barrier FROM TO MATERIAL FT PLAcsM@irME/HODt OStotruwater-Drainage 24 D• 34 & to gramPam s1avttyal Technology Subsidence Control ft. fi(Closed Loop) D'fracer 204;DltI1 i3NC'cif: addlfTosal'sliestslr"" -"
R�Dn _Other( under#21 Remarks) FROM TO DI StFIPf10M hadsm aeWroek da
1 R 4 D• yeD-br wnday
4 Date weB(s)Clrmgletsd:21 OCt 21 well ID# 4 M 10 D-
_ rswid
S&Well Location: -- --- -- --—— _— -_-__ � ft. 12 fL 1pa7r day
Ronda Hbmon 12 D• 15 D• giaysand
FaerliWOwnrNante Facility W#(ifapprteable) 1e D- a D. Wayc'my
252 Four Forks Rd,Shawboro, 27973 22 lL 34 n. grays—
Physical Address,city,and Tip R %
Cilrriluck
Canty Parcel Identification No.(PIIO
Sk Latitu&mdlnai&WeiRdegreewlnhmtes/secondsordeclmal degrees:
(dwellfield,onebul-gasvlHcicro yy erbfd
36-37910 N -76.06423 W
6.h(an)the weRNOPammumt or
[:(temporary Si if odm well p Darer t
fG.f ays+gmeg,bisfong Lbesebv d"dK
7.>atIaa .eo(s)war(ove) ivacs»�dame
repOrtoaa well: Yes or I@No wnl[SANCACOW-01Wor15ANCACWC.D200 Well CmW1rmtimrSmmdads and dWa
IfAbbstsepnb cP.r'qfr3isrWardlmrbcenpwided6a�exdloanv.
repairum&rVlreamilzi Ioaoroadieba*ofdusfmm
23.Site dbWamol additional well ddaBs:
&For GeaprohdDPP or Closed-cep Gehl We%having the same You may we the back of this pW to provide additional well.site or well
construction,only 1 GW-1 is needed.Indicate TOTAL NUMBER of wells Construction details.You may also attach additional pages ifnecessery.
SUBM"AL INSTRUCTIONS
A Tatai well depth blow Ind sa rhm 34 (R) 24s.For All w Submit this form withm 30 days of completion of well
Farau*gde-eft No gill dprt sf&ff—f -0-3 OD'and2WO01 constriction to the following.
_ 1&- -bow"Of f tom) Division orwater Resources,Uoanoffion ProcesiDg Unk
4rvAz erlevd is abase camA we +' 1617 Man Service Ccow,Rsldgh,NC 27tW%4617
IL Borehole diameter:4 7/8 (m,) 24b,For Iniedlon Wma: m addition to sending the farm to Me address in 24a
12.well coffin®d]lod: mudrotary ab°Pe,also submit one copy of this furl within 30 days of eoulpietion of well
(�mmger+aeaiy eslrk,diroctposh etc) construction to the following:
Divishm ofWater Reoarces,Underilrowd IDject—CtlntrW Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Ralelg6,NC 276"4636
13a Yceld(gpm)20 Mdhod of test pacer pump 24c.For water Strook&Inieetron wellst In addition to sending the form to
the addresses)above,also submit one copy of this form within 30 days of
13b type: I1ypoChDltbe 3OZ completion of well construction to the county heahh I artmdrt of the euunty
where constructed.
Form GW-1 Nonh Carolina DepaMent of Environmental Quality-Division of Water Resounxs Revised 2 22-2016

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