GW1-2022-03435_Well Construction - GW1_20220318

Jan. 29. 2018 10:58AM Env. Health . No. 6711 P. 1
WELL CONSTRUCTION RECORD!GW-1j For Internal Use Only:
I.W,1 Cootracto InformRdo
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NC Well Coab¢cTor Cetti4c4don Number q$"'OUTEWCASIM. 6win aced-iveIIs:OItLIl�R •- tt�itMe "a's.
i FROM TO DIAMETER THICXNESs MATERIAL
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2•Well Construction Permit#: 1 / FROM To I owmm I TRICIaCss I M&INRIAL
Llttalf applicable wep eonnnation penults 0.e.WC.Cowry.Sans,Varinnce,ere.) tr k. to
3.Well Use(eheekwell use): n k. fn.
W ater Supply Well-
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Agricultural r1Municipsypublic 0 fr. IL tai
Geothermal(HeatinglCooling Supply) DResidential Water Supply(single)
IndushieUCommcreiol 131tesideatial Water Supply(shared)
Irrigation FROM To MATERIAL ZMPLACEMEIffMETHODa A D—U?u
Yon-Water Supply Well: 0tL O " . s
Monitoring ❑Recovery ft. It.
IDJecdon well:
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_ AquiferRecliarge OGroundwateritemediation �___
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AquiferStoragaandRecovery QSalinilyBonier FRM TO MATERIAL EMPIACEMEN bOCT11011 -
_Aquifer Test ❑StortnwalerDrainage n ft.
Experimental Technology Subsidence Control n tt
Geothermal(Closed IMP), E)Trwer 24A 61AO aifnili eQdHtaNeirilimtsTtim`aeiie _-_ —
_Geothermal(ReatinglCauling Reim) Cthef ex lain under#21 Remarks now I TO DfSCH�rIDN atar,dndnas.sotYtark y' -f�sce ctc�u
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4.Date Well(s)Completed: n Wen IDS Q �
Sa.WellLocatiom vo00 ,:5`J k0A 4.An An,
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Paeili ws. Name PaepityWil ifc tieabte) O R
rylo.. ( DF rrs'.'t Cis
rr. nPhysical Mdmu,City,aad Zip N.Le a�O � n ft.
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Couaw Pmcel IdeaAcation No.(PIN) t°
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Sb.Latitude and longitude in degretwWauteslseeonds or decimal degrees: " Ism
(ifrrell Held.oneladlongissuffident) 22 Certification:
3s.as If"f y N -$/.0/8t'P p W I 3,t
6.Ts(are)The well(s)OPermsuent or QTemporary Sigtnnaeo cnided Well Contractor Date
By siS dng ddt/arras I herefy emo that die weB(s)um lkere)couhvefed A»accotdame
7.Is Ibis a repair to an existing wen' ❑Yes or o with 1Sd XCAC 02C.O100 or 13.f NCAC 01C.0200 Well Carnnfcrlon 8madontt and chat a
((d u tsa regal►,Jlfl ota lrrawsf cod(eanrrtuedaa G rnmtian at etplam the namm of dte eopyofrhis esewd 1=been proMid to the wall owner.
rermr under 021 mmarlr recdan or on the had ofthufom.
23.Site diagram or additional well detags:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to pravide additional well site details or well
construction,only 1 GtV 1 is needed. Indicate TOTAL NUMBER of wells constitie ioadetails. You may also attach additional pages if necessary.
drilled: �^' SUBMITTAL INSTRIICI•IONS
9.Tots[well depth below land surface J 1�0 (h.} 24a. For All Wells Submit this form within 30 days of completion of well
For myinplcwcns jut atldepthrJdff—t(rsampfe.1@2W,md2@1M conametion to the following;
�10.Made water level below top of casing: .3 (f1.) Division of Water Resou I rces,Information Processing Unit,
lfwater revel Is abate earhrg we"+" 1617 Mail Service Center,Ratelgh,NC 27699-1617
11.Borehole diameter=�(in.) 24L For Infection Wells: fn Addition to sending the farm-to the address in 24a
12.Well construction method: Y'! above,also submit one copy of this form within 30 days of completion of wail
(La.mgc!r.rosary,cable,dirt push,cto.) construction to die following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY Wlfi T f ONLY: 1636 Mao Service Center,RalciS14 NC 27699-1636
13a.Yield(gpni) 3s Method of tesn- r - 24c.For Water SunDhr Fc Inlecdon Wells: To addition to sending the form to
the addrms(es)above,also submit one copy of this form within 30 days of
13b.Disinfection type: A/ Amount: 4 Lcka S completion of well construction to the county health department of the county
%x&cro consinicted.
FotmGW-I Ne"kCmafkmDepartasw ofEavimemeanlQuaNW-Division ofWaterRwoarees Revisod2-22-2016'