GW1-2022-02979_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(GW-1) For Internet Use Only:
1,wen Contractor Infor/maati/owL.
70 V7t 14.WATER ZOM
Well coa ntctorName FROM I TO DBSCRIPIM
4�0-
NG Wett Conhvxft r Ccct6mtim bombes
F
yj o,Ax- tj Z.4L� ; FROMI
TO DlAtit$Tllli TlffCKNE98 MATERIAL
- % ia. _1 Company Namn
16.DOMM cum OR TOMdosed4aiml
2.well Construction Permit#: FROM To DL41M 93R 11HICKNEW MATERIAL
List all applicable well constnrctinnpermits(fa b7C,Comity.State,variance,etc.) R• & in.
3.Well Use(chechweU use): fL R• m-
water&uPPIy Well; 17 s
FROM TO DiAN1RM SLAT MATERIAL
Agricultural �MuaicipaUPublio t,J. a O3 N
31
eothermal(14eating/Cooting Supply) esidential Water Supply(single) & g, ` ilJ.
Industrial/Commercial Residential Water Supply(shared) ]0.GROUT
lrriRadon FROM TO MATERIAL EMPLACEMBlVTMR1$OD&AMOUNf
Non.WaterSupply Weil: D• 3 /J _
IAP
Monitoring MOM fL
Iyjectlon Well:
AquiferRechatge DGroundwaderRannediatioa
infer S ����'PACK rf anallcubla
A9 tango and Recovery Salinity Banricr FROM To MATmtrAL t nr NrMBMOD
Aquifer Ted O&OnrwaterDrainege fL ft.
RVerimentelTechnology DSubsidenceContrul & £t �
Geothermal(Closed Loop) 13Tracer 20.DRKU qGLOG fattachadditionalallm(sE
Geothenpal. Retort Other lain under#21 Remade) I FROM To DBSCRIPIYON Caron hPORM sonGaek
4.Date Well(s)tbmpleted:JS-� wen W# ft. it•
. 5a.well F.ocatton: tt. s. t
a. &
Facility/lhmerName Facility ID#(if applicable) ft. R•
Mysical 2ip ft. rt. MW
21.ItENLM 8S
County ParcetIdentificaboallo.(PII�
3b.Latitude and longitude in d t *, :r , ;-� �.,�. •, , :•,:;,
Itg egt+ees/m►nutes/seconds ordecimatdegrees: .�"�. :•,{`-;y,,,,,
(if well field.one taMong is sufficient) 27.Certitica on:
36.D. 7:z 9 W 302y. 43-,W-2V
ti.Is(are)the wells) ermanent or 13Temporary Si o£Ceetified well Date
� By slgnfng this farm,I harby col#yr that the we0(s)teas(me)a m ntrcted to awmb7ae
7.Is this a repair to an eldstingwen: ElYes or 0•V tvith 15ANCAC 02C OZW orJSAMC 02C,0200 Well Conurttctim:Standards and thar a
If*&isarepab:fit out known well cotwrucdan tnfornmtion and aWrato the noure oldw copy ofthis record has he=prwidedto thewdi atmer.
repair under#21 miarbsectton or on the back of this form. 23.Site db gramor additional well details:
9-For Geoprobe/DPT or Closed-Loop Geothermal We11s 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 TOTALNUM ER of wells construction detailL.You.may also snub adilitionat pages if utowaW.
drilled:
9.Total well depth below land sm1aee: lized (R.) yqa,For All Wells: Submit this foam within 30 of
For multiple welts 0st all depths ifd trem(em wle-3 a@200-and 2Q1009 completion of well
constructiontothe following:I
10.Static water levei below top of castor: y� (ft.) Division of water Information Processing Unit,
If water level is above casing,use"a-" 1617 Mail Service Center,Raleigh,NC 27699-147
11.11orebole diameter. 6 (h/r.) 24b.For Intection Wells: In addition to sending the form to the address in 24a
12.Well construction method: t>�0 above,also submit one copy'of this foam within 30 days of completion of well
(Le.angm rotary,Jubly di edpns>,eta_) consitucdiontO the foliovring f.
Division of waterIte�+cea.UJndergr+nuad bdeetfon Cant mi Pro
FOR WATER SUPPLY WELLg ONLY: 1636Mai Ow rho Centw,Wvkh,NC 2769916� 1
13a.Yield W" / S Method of ust iB bum 2 Fbr Pater SuM&hnie M Wellrti In addition to sending the form to
the address(es) abme, also'submit am copy of this form within 30 days of
13b.Disinfectlon hype: Amok /a awa uS cOmpietion of well construction to the county health department of the ommty
wbem commuted_
Foy GW-1 Nm&CaroUn&DepanmmtofFa►vlmmmntel Quality-DhWonofwa mteRssomvea
RJlvised2-222076