GW1-2022-02961_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Oniv:
1.RGntractor//��inform`ation:
1te,OW 14.WATER:7ANES
Well ContmctorName FROM TO DESSCRiMON
R. R. .
NC"ell Contractor Certification Number 11 OLTER CASING ifor muldtased webs OR LINER cable
ICIA{``wn FROM TO DIU1lE76R THiCiCII'FSS 1LTMUL
\` W & R In.
Cwnpany Name
/7 1 16.INl11ER, S G ORTUBINGlaebtkirnuill ilaimUntint
2.Well Construction Permit#: < 6 O� ��/_� FROM To I DmAIErER TH►V&X'Fss ?1L1WRLAL
DO all applicable well amvtrraian pernrity ri .VIC,!'tnmtr.Slate.i lWance,etc.; ,� R. Lt fL (,t - .in. �'/• (,1 J �(c
3.Well Ilse(check welt use): ` R. 5'3 Lki1 JSd`T�l LC1`i wa c—
IYater Supply Well: 17.SCREEN ,
FROM TO r DWAiETER s1.OTseE fuici ms T M 7:m A7 _
,Agriculturnl Munici aUPublic
Cl p Oy2tl. -SI tl. � is 036 Sc��o
Geothermal(Heatin0coolinQ Supply) Residential Water Supply{single) ft in. .
Industrial/Commercial Residential Wow Suppir(shared) 1s GR011r ~'
irri Lion FROM I TO AIATERUL E11fP1 ACE IENT MrMOV A AMOUNT
Non Water Supply Well: o R• 3 5' tt. &M e""NI.
�
_ Monitoring ecovery fL fL
l
jectionWell: ft. ft.
Recharge QGroond%wdter Remediafion
Aquifer Storage and Recover OSolitlity Harrier FROM , TO 19,SANDIGRAWL,, ir • life)
MATERIAL E ACMIEh'TAWrHOD
it. iL
Aquifer Test [ stormwater Drainage 3S 1 C4 ouExperimental Technologv [Subsidence Control ft R.
Geothermal(Closed Loop) Tracer 20.DRILLIN
G LOG attach additional steels Nneecssa
Geothermal(Hearin Cooling Return) Other lain unifier#21 Remarks) FROM TO DESCRwno% edor.ha�e:,•muroek 'araht Sim etc
M R.
Q + '
4.DateWeli(s)Completed: 2•iA IX WWII ID#f1CW W 5 fh fL
SR.W 1 Location:
it. fl
• V 0 it. bT 3
Facility/Owner Name Facilitylpi(ifopplimble-) R• ft. "
`5 D NG $Olv S rara N fL ft.
P]n sical A— City.and Zip ^ 7 V0 AG R. ft
•`t v— O 21.RENIARIKS
?. .
County Parcel ldea ication 'No.(PIN) m -Ifisr-� R-
Sb.Latitude and longitude.in degrees/minutes/smonds or decimal degrees:
(if well field.one iat/long is sufficient) 2 ertitieaN n;
3S,100\OUO N -7.6N 7 "t\�j wV\lr—N2 .2$ 22
6.Is(are)the weil(s)OPermanent or [3Tentpornry a SilmaturofCertified Weli Contractor, pate
qr x4ming this farm.i lmtvhr cr'trifp Thai the welfls)ti av firer-)crmsintcted in acsnrdmire
7.Is this a repair to an existing w elk - yes -or E990 tiilh 13:1 IW IAC 02c.olua ar liit AZAC 0C.o2110 li'ell Construction Rmutant,wid chat a
(/this is a repah;JU/abi kimm irell rmistrudimi it?furniailon raid egdain the mature afthe CM1 Dflithr IVCdni har been phnided to till corner. ,
repair raider-21 reran rsawan-rot an the hack itf thisform.
23.Site diagram or additionat-well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal[Wells having the same You may use the back of this page to p oyide additional well.site details or well
construction.only 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional paces-if necessary.
drilled: ? SUBMITTAL INSTRUCTION'S
9.Total well depth below laud surlhce: ­�t3 (ft-) 24a, For Au Wells: Submit this form Within 30 days of completion of well
For mnitlple u illy ttrt all depths iifdI erem(txamp/e-3@200 and 2@1001 construction to the following: a+,
10.Static water level below top of casing: S ow Division of Water Resources,information Processing Unit.
if muter terel Ev ahaty caving,rise 1617 illail Service Center,Raleigh,NC 7699-1617
11.Borehole diameter: (in.) 24b.For lniectiou j1'elts: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 da)s of completion of Neil
12.Well construction method:
a construction to the following
(i.e,anger,ratan',cable,detect push,etc,)
Division ofWater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 2760-1636
13a.Yield(gpm) Method of test: lac.For luster Sunniv&IaiecdowWAIr. ,in addition to sending the form to
the addresses) above= also'submit pre copy of this form within 30 days of
13b.Dlslnfecdon type: Amount. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Denaament of Enironmental Oti itt-Dhision of Water Reen,.roec