GW1-2022-02988_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(QW-1) For internat Use Only:
1.Well Contractor Information:
oc ��t I&WATER ZONES
Well Contractor Name FROM M DISCRIPTIM!
L4(-I RS — C —758' �U �' 6C Kinw
M ft.
ORIUMMOr
NC Wall Contravmr CaeH�1!i '
F$OM TO r DIAMETER T1IIr$NEss MATERIAL
CompanyNamo
16.lNNER CgBING OR T DING clesed-lamil
2.Wen Contra iou Permit#: mom I To DIAb== MUCKNESS I MATERIAL
List all applicable well aonstrucdonpemdts(i.e.b7C,County.State,l4wimnce,e1m) ft. I R. I �• Q� OJ C,
IWell Use(check well use): % R• ii•
Water Supply Well. 17.SCRIMN
FROM TO DUb1STRR SLOT TBRIAL
Agricultural �Municipal/Public o ta.
Geothermal(Heating/Cooling Supply) esidei»ial Water Supply(single)
Industrial/Commet ciai OReddential Water Supply(shared) IR GRODT
hsi Radon FROM TO MATERIAL EMPLACFMKNTMSTHOD&AMouNT
Non•Water Supply Well: IL h 0 N-
Mon3toting & ff•
kdecdon wen:
AquifbrRcdmW OGrutindwatorRemediatiom
utfi:t's 19 SArmt�Avra. � �
AQ Stomp OSalliftBan'ier FROM To MATERIAL ER94ACHROMA MWD
Aquifer Test OStonmwaterDrainage fL ft-
fterimentLti Technology DSubsidence Control ft. &
Geothermal(Closed Loop) OTracer 21 DRHMQLOG latlachadditionalsinsisif
Geothermal ftathWCooling Return Other lain under#21 RemadsL) 1 FROMI TO DESCRIPTION color,hanULtsh s Wm*
IL &
4.Date Wev(s)Con pietub Wen w# A 2 (e44 f- .
go.Wen Location: R' ft.
FaciliWOwnerName Facility M9(if applicable) R• ft.
fL. ft.d'� p�
Physiod Address.City.and Zip M ft. '
�ex�on 21.P
Cc" Paicel IdentificationNa.(PII3j r"i
fib.Lat tade and longitude in degreesin inuteslseconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
28.�(o go N - 1 .()Sly7yy w C--- 9-7_G _ _ 22—
6.Is(are)the we1Ks) Permanent or OTemporary Sigaatcae of a Vell Cantraotor Date
By signing 41 1 hereby certify that the welts)mat(were)cnnsnr,cred in accordance
7.Is this a repair to an existing well:Al.1jbMNdOnandapjgfO#XA==OJFft
es or DNO with 1SANCAC 02C.0100 or ISANCAC 02C MW Well Conmcticn Standards mid drat a
If this lsarepain fill out known well avrt m ropy ofWs record has been provided to the weft a+mer.
repair under#21 remarkssectlon or on the bark ofdds form. 23.site dhqnmor edditib]ml well detail
g.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site detmb or well
construction,only 1 GW--1 h needed. Indicato TOTAL NUMBER of wells construction deteML-You may also attach additional pages Nnecessary.
drilled:
�1Y11T'PAL LN3TRIIfTIANs
9.Tota1 wall depth below land surfaces CID MCI zaa.For An Wells: Submit"this form within 30 days of wmpletion of won
Par nwtdple welts Ust andepths Iffi{fferent(Pxarnple-3Q200'andlQa 700) constructioutDthe foDowing: '
10.Static water Level below top of casing: 7 (ft.) Division of Water Resources,Information Processing unit,
11water level is above casing,use"+" 1617 Mall Service Center,Rale*b,NC 27699-1617
1
U.Borehole diameter:_-(h,.) 24b.For Inlection WeLiss In addition to sending the form to the address in 24a
IL Well construction method: roy,,,e eve,also submit one copy of this form within 30 days of completion of well
(Le arm�,.-bk di�etpask etc-) construaion to the foAowing
Division of Water Remtiinees.Undeig,ound 7naecOm Contmi Pa+ogram,
FOR WATER SIIPPLY WELLS OI!II,Yt 106Md OUTI C Center•RalOWNC 17fi49 US
I
13a.Yield(gpm) Mefltod of teak PAMQ 24c.Fbr Water Sm>roiv&Iniection welly In addition to sending the form to
13b.Disafection type: _ Amowot: /�'L the addross(es) above also submit are copy of this form within 30 days of
completion of well construction to the county health department of the oowuy
where constructed.
Foffi GW-1 NciaicarmliaaDepamn®tafPnvdremr entdQmUty-Div donofWata<>ae: Rev sed2-22ao16