GW1-2022-01178_Well Construction - GW1_20220121

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ArELL CONSTRUCTION RECORD(GW-1) For Int penal Use Only:
1.Well Contractor Information:
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Z.Well Construction Permit i`:l i `et t - FROM To DIUMETER THICKNESS MATERIAL
Lust all aapticahle tszll eonsauctioa permits(r a UIG Couab State,Variance.eta) & M m'
3.Well Use(check,well use): ft. it,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER sLorsnz THICKNESS i<:1
Agricultural �MunicipaifPubIjc ft ft. in.
Geothermal(HeatinglCooling Supply) .Residential Water Supply(single)
t1IndustriallCommercial `e�idenhal Water Supply(shared) _ .
C—� 18.GROUT
litrigation FROM TO MATERIAL nUgACEMfiNTMETHOD&AMOU14—
Non-Water supply well: IL ;L46 fL
Monitaring Recovery ft. ft.
Injection Well:
R ft:
Aqui br Recharge Groundwater Remediation 19.SANDIGRAWL PACK bid '
Aquifer Stomp and Recovery OSelinityBarrier FROM TO MATERIAL I 0n%ACEMENTaMWM0D
Aquffer Test j3StormwaterDrainage R &
Experimental Technology Subsidence Control R•
Geothermal(Closed Loop) 13T,,imr 20.DRlLLII1iGLOG attach additional sbeats if a -
Geothermat(lieatin lCooftRehm) Otber(explainunder#21Remarks) mom To DtiSCRO'llON few or.buft0%sawrneit e. duets-)
ft. a ft.
4.Date Well(s)Completed: Well IDgjig
R ti;
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Sa.Well LoVdan:
uie
Faoilit ow-cer..ame Facility IM(lfapplicable) R'
P$rsi,�s ,City,and zip M ft.
21.REMAPKS
Cotmty Parcel IdentiocationNo.(PIM
5b.Latitude and longitude in degreealminutesiseconds or decimal degrees:
-on zer,L o=--ta_3oa8 is safncie,) 2 _Certlflcation:
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6.is(are)the well Perm2nent or nTemperary Si tune ofCatified Well Contractor Date
Sy igning this form,7ltereby c tr,fr that the u ellg)was(were)constructed in accordance
7.7s this a zzpalr to an existing well: []Yes or 0C 15.4 NCAC 02C.0I00 or 15ANCAC 03C.0200 Well Coastructian Standards and t/mt c
Ifthts ita rr•»-,:mar:^:a:aa Neil carstrrrtian information n lain thenatnre of&a copy ofthis record has been provided to the well owner.
repair a ndkr t2l ra-x h-bzaefon or an the hackofthisform.
23.Site diagram or additional well details:
&For GeoprobdDPT or Close d-Loop:Geothernet Wells having the same You may use the back of this page to provide additional well site details or well
constrlctitffi,only I l is>±eeded indicate TOTAL NUMBER of wells construction details.You may also attach additionalpages ifnecessary.
drilled: J ( SUBMITTAL TNISTRUCTIONS
9.Total well depdn below laced surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all dzaGs ifai�rffant(-=pte--3@2W'and 2@100I construction to the following'
1o.Static water level below top of easing: Q OQ Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehaIe diameter. (in.} 24h.For Injection Weiss: In addition to sending the form to the address in 242
p� s above,also submit one copy of this from within 30 days of completion of well
12.Well construction method: ►'t 1 construction to the following•
(Le.auger,notary,table,direct push,eta.)
Divis?oa of Water Resanrrds,Underground Injection Caliin'el Fr i•b:H�•�,
FOR WATER SMPLY'VVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm)� Method of test: � 24c.For Water Supply&Injection In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type IlT RA Amowab completion of well construction to the county health department of the county
where constructed_
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