GW1-2022-02984_Well Construction - GW1_20220302

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WELL CONSTRt MOIST RECORD(QW,1) For btaind Use Only:
I.Wen Contractorb%rmation:
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Well Contract ?T= FROM I TO D>iSCRiPigoN
ft.
NC Wei!Contreeinr C-dsQao®tiomear A
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1.Well Construction Peradt d: 1 ©!J / FROM TO DUMEM I MU MAMFff&L
List all applfcablewall comPuctlon pMub(m UIC,County,SWU6 Vwfwwe,err~) & jib
3.Well Use(cherkwell use): ft. ft. hL
Water 5npply Wen: Stet
Agricultural PRM To D sL04 TERtAr
0
cipal/Public fr. ft. i Fm
t1ndustdal/Commerdel
thermal(Heating/Cooling Supply) ideatial Water Supply(single) ti. t3. ill.
DResidentfai Water Supply(shared) 10.GROUT
pn FROM TO MATEM" EMPLACttbTWh 6THOD&AMOUNT
Non-WaterSoppW Well: J9 IL R- .31
U!'
OnitOring &
Itpecllon well:
ft. ft.
AquftRc*arge DCaoundwaterRemedialion 19.SAlWM&VBL PACK !licsM
el
Aquifer Storsg WdRecovery DSalmtt l3anier FROM TO MATMAL SiI�LACBdISW OD
Aquifer Test OStomlwaterDrainage ti- M
EVerimental Technology Dsubsldence Ctmtml
Geothermal(Closed Loop) Tracer 20.DRIIMGLOG lattachaddilional i€
Geothermal Coolie Return) Other(explam under#21 Remarks) I FRoM To DSSCRWUON color hesdn
ft, ft. U r: s r S c.V..
4.Dabe we11(s)Courpleted: -(�-Zveamp2-9
.
So.Wen Location: �. f.
Q a /
Ems_ cz�-,��
FacilitylOwnerNuae Facility M#(if applicable) % ft. ;`i A Y t t„ P.-1
� ) 1 eft. Ir"Aa.ae 9 /� ;it 11 e ft. 1
phniaal Address.Qty.andtip
pl—�l%J— y,
-( 9-7L/S26 21.RFd►Z6R88
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County Parcel Ideotifirati=No.(pIl3) i'� JL.i
SN.Latitude and longitude in degreeslroinuteslseconds or decimal degrees:
afwell field.me Istllong is sttffident) 22. ti
35iDSS%�, 'iv 799 1.0°37. 6Z7- Zt W
6.Is(ar+e)me well(s)90ermaaent or Memporary 8jgq#1ureofCufdfiedW1ffQdF4dor Daze
Sy sighing this fwm I hereby canify that the weW(s)was(nett)canstrarted In amotdimce
7.Is this a repair to nu eiastimg well: DYes or with 15ANCAC 02C 4100 or ISANCAC 02C A200 Well Constracdaa Standards and dire a
ff this is arepair,jW out kmm well construction injormaWn and eaptafn the nowreofths ropy ofthls reeotd has bem provided to the weft muds.
repair rmder021 renrarbsecdon or on the back of diisfom
23.Site di$gEam or addiijarrol well delar'lx
S.For GeoprobelDPT or Closed-Loop Geothermal Wens 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 Wnstmetion detasilL.You may also attaab addtional pages if necessary.
drilled:
9.Total well depth below land surfaces Q Q/ (ft.) 24,For All Wells: Submit this form within 30 days Par muldpk wells Ust ail depths ifdtf'erent(axample-3Qo and 2®100) construction to the following of completion of well
10.Static water level below top of rssrog: 2 S (ft.) Division of Water Resourms,Information Processing Unit,
V per level is above easing,use"+^ 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. �� Yg (in.) 24b.For Infection Weliss In addition m s ending the form to the address in?Aa
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(Le.augur ma's.eabK dixectpask ere.)
construction to the following:
Division of WaterResoorces,Unde geoaind D dection Cal rrognun,
FOR WATER SFJPiZY WELIo9 ONLY: 16%AW&rv6 Center,88telgll,NC VSX1636
13a.Yield.(gpm) T Method of teW r% :@Qc.Fbr�DMr Sun&&Injection Welts: In addition to sending the form to
13b.Disinfection type: H 1 H Amou 6>mow.. ES �comple (� construction 9180 o the one cW of fils form within 30 days of
where Courant & °t of the county
FounGW-1 North Carolina DVmmiaatofPavironmeotolQo hW-DlvmonofWawReaaatoes Revised2-22-2016