GW1-2022-01547_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GWA) For Internal Use Only:
1.Well Contra(cto`r Information:
�.i�l/'n � r�L�► 14 WATBR ZONES
Well ConttactorName FROM I TO DBSCRWICION
me Wert -Yruvm
FROM I To 4 AI DIAM6TSR THrQCN688 MATBRiAI,
Ccm�panyxame D ft. /00 fL -Vo 1 PV6
16.no=CASING OR T{1BiD(G t>urmal dosed-lot
2.Well Construction Permit : FROM TO DIAWWRIt I THICtINRER I MATBRiAL
List all opplicable well consMxdon pemeits(i-UIC,County.State,Variance,etc.) ft. tt. fa.
3.Well Use(check well use):
Water Supply Nell: IM SCREW
FROM TO I DUMMrM gWrS= MCOMS MAMMM
Agricultural icipal/Public 0 g. ff, In.
aeothannal(Heatieg/Cooling Supply) ffResidentid Water Supply(single) ft. ft. in
Industrial/Commercial DResidential Water Supply(shared) i>&lRtOt7T G
11nio0on FROM I To MATBRi L I EMN ACEBUMM MOD AMOUNr
Non-Water Supply Well: Q
fL A c Al
Monitoring Recovers, & k r'c
redon Well: ` " AO
JAquifer Recharge DGroundwaterRemediation 19.9ANWGRAVEL.. fif
Aquifbr Storage and Recovery OftlinityBarrier FROM To I MATERUL I EMPLACEMERMEMOD
Aquifer Test OStotmwaterDrainage ft. ft.
Experimental Technology DSubsidence Control fL ft.
Geothermal(Closed Loop) Tracer 21L DRII.LING LOG attach additional sheets if suawary
Ocothecmal Conlin Return Other( lain under#21 Remarks) FROM TO DSSCRiPTTON tutor amVrodc
4.Dabe Weil(s)completed:-: l20-21 wen W#1���Z bf, ft. tt. a� y
So.Weft Location: L19it.
�
�—/- 431�c &I ft. ft. i 20 r'
Facility/OwnerN e � Facility II9(if applicable)
% ft.
9k2 L � 9 / ft
C_ . •
;t1or,ti t QcW,
Physical Address,City,and Zap ft. ft. v
ACSC)/1 21.RBMARi S
County Parcel IdentificationNo.(PIN) �rn 74 Li
5b.Lailtade and longitude In degrees/minutes/seconds or decimal degrees:
(lf well field,one k4oug is suffcclent) 22.Ce 'on: I
3to o S39632 N —7�n I& w
6.1s(ase)the weU(6) armament or Temporary Sigma of ed Watt Date `/
By signing this form,l hereby amW that the wrXs)was(were)consructed In aacorda we
7.Is this a repair to an exisfing well: DYes or Ell or with 15ANCAC 02C.0100 or 15ANCAC 02C MW Well Conmucdon Standards and that a
If this is a repair,fill out Anown well construction h*7nadon and axplain the nature of the ropy of ft record has been provided to the well owner.
repair under#21 remanfssection ar on the back of thisform. 23.Site diagram or addifioril well details`
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bad of this page to provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction deWs..You may also a8ech additional pages if necessary.
drilled: SUBNIITTAL DVSTRUCTiONs
9.Total well depth below land surface: 7 D ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(wxniple-3 a@20 and 2Q100) construction to the f0110wi11g:
10.Static water tevei below top of casings 2 S (f6) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter. �J (in.) 24b.For Infection Wells: In 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
12,Well wristnrction method: construction to the fbHowing:
(Le.auge.-toy.cable directgash,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Undeagromid Infection Control Prograan,
16M Nei!Service Center,Raleigh,NC 276991636
13a.Yield(gpm) fa Method of test: (0-V11 Z��"'+ 24c.For Water SnPPk&hdection Wells: In addition m sending the form to
/► the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Am mnft completion of well construction to the county health department of the county
whem constructed.
Form CAW-1 North Carolina Department ofEnvirotunw l Quality-Division of WaterResanraes Revised 2 22 2016