GW1-2021-00543_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For hzteraal Use Only-
I.,Well Contractor Information:
-14.WATERZONIS
FROM TO DIISCEMON
Well Contractor Name
3a2*-44 �r
XC Well Conbs tmCceafi=th=Nember 13.OiTI�itCASIIYG ,mails=tgsea walla OItLII'I1Mt lltaDte
I ny Lj I FROM TO DIAMM TMCKNM MATMAL
Company/i��Name D f. , in. SAe zi
16 RMER CASING OR TUBING fE2&zrnd dwed4ocul
2.Well Construction Permit#: 2Aa 5 FROM TO DIANQ+°iSR THiC1QrESS MATEMAL
Fist ail applicable well consimcdon permits(i e.UIC,Comity,State,llarIM,etc) ft. M in.
3.Well Use(check well use): fL R• hu
yPater Supply Well: f.PROM
,
To urAtHeTen si.tvrstze xmcrflvass MAMMAL
Agricultural icipal/Public �'CSv 0 fL
Geothermal(Iieating/Cooling Sup ft. tt. ,
Ind aUCommerciai Residential Water Supply(shared M GROUT
FROM TO MATERIAL E M ACSMBNP METHOD&AMOUNT
Non- aterSnpp(y Well: D' D'
Monitoring Recovery ti~ ti.
Iq( on Well: ra
ft. ft.
Aquifer Recharge ElGrouttdwater Remediation 19:SA1VDIt,RA4EL PACE f licabie
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO MATERIAL EMFLACSd1ENP METHOD
Aquifer Test OStarrnwaterDrainage ft• R•
Experimental Technology OSubsidence Control M n•
Geothermal(Closed Loop) nTracer 30.DRII U gGZOG attach addit
Geothemral eatin Coolin Return Other(explain under 921 Remadss
FROM TO DESCRIP'riON(voter herds saWn)t c
ft. ft. I/C c
4.Date Well(s)Completed: l.i'l2•Z i Well w# ft. I `` � s t
5u.waif Location: may'2 ft. L
ct 414 -L &* ft. M
Facility/Owner Name Facility 1D#(rfapplicable) R• R• N
ft
auto HAt�� 41- .5f-/n,- rr M .
Physical Address.City.and Zip f t. R'
�A S 21.RBMARS.S
Coanfy Parcel identificat-son No.(PIN)
5b.Latitude and longitude in degrees/mMuWs/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce ea' n:
. ��3LstH7_2!s—aN ?O �lyi�.,•y9'T��t W
6.Is(am)the weU(s)Q#ermanent or 13Temporary -sipadineommtified wee r Date
�✓ By signing this form.I hereby awn&that the mills)ivas(were)constructed m accordance
7.Is this a repair to an exis ft well: Dyes or WO with ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well aonumcdon informarion and exphdn the nature of the copy of this record has been provided to the wet owner.
repair under#21 remarks section or on the back ofill s form.
23.Site diagram or addittoaai well detail s:
8.For Geoprobe/DPF 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 GW-1 is needed. Indicate TOTAL.NUMBER of wells construction desils..You may also attach additional pages if necessary.
drilled: SAL llvsrRller><olvc
9.Total wall depth below land surface: 46 ; IN 24a.For All Wells: Subink this form within 30 d
For multiple wells fist all depths If different(exatnpla-3@200'and 2@1005 days of completion of well
construction to d1e following:
10.Static water level below bop of easing: (ft.) Division of Water Resources,Information Processing U
If water level is above casing,use"+" 1617 Mali Service Center,Raleigh,NC 27699-16
It.Borehole diameter. 24b-E'gr,1nieetion Wells: I&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
U.Well construction method: construction to the following:
(Le_auger rotary.cable,dircet push,etc.)
Division of Water Resourcw,Underground bdaction Controi program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield W" .fin Method of test jq/ w,% 2 Q•a: 24c.For Water SuDviv&Injection VPeUs: hi addition to sending the form to
the address(es) above, also submit one ropy of this form within 30 days of
13b.Disinfection type: L�7/-� Amount: L.A completion of well construction to the county health department of the county
Where construe
Form GW-1 North CarolinaDeparmaent ofEnvironmentai Quality-Division of WaterRemmes Ravised2-22-2016