HomeMy WebLinkAboutGW1-2022-03437_Well Construction - GW1_20220318 i
Jan. 29. 2018 10:58AM Env. Health No. 6711 P. 1
WELL CONSTRUCTION RECORD f GR►_1� For Internal use Oniy:
1.W 1 Cootracta I11
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Well ConaacwName QO it
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NC d Coaaac Certification Number X-OVIER-CASI?liti: mi:[�ells:o LtPER f- 'liei:b(cle..�:_,F�.^�:
C e FROM TMMIFS
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'�rO r3�I1tNEA'C'ASIi4Q:OR''Cbltit+[G? ..1>•amar:cCoic'd-1iC'uw,. ..=.-t�-=.t==.=a•
L Well Construction Permitil:, FROM TO 41AMMA 'MCKNEUs I MAMM"
/,(pall applimble-Mu cntutneeaonpetrnns(l e.urc.County,Stare,Vedance,etc) [t R. 10.
3.Well Use(cheekwell use): It. R. I to.
Water Supply%Ven: mom I ro I DtAM¢T a SLarsiM .Tuiewvr&S 1 MATFRrAL-_
_Agricultural MmunicipaHPnbljc 0 rt, IL in.
Geothermal(73mting/Cooling Supply) Residential Water Supply(single) a. IL in,
_IndustriWCommemial Residential Water Supply(shorw)
t ' tion Muhl TO MA AL >srma a atEIHOD h ,u
Yon waler Supply Won-
Monitoring oRecovery rt. tt
Inlecdon well: &
Aquif4fReebarge dGmundwoterRemediation
Aquifer Storage and Recavezy DSalinityBotrieC FROM To MATERIAL tsrNPLA MCrt[OD £:r
_AquifrrTcst nStormwaterDrainage a tt
Experimental Technology DSUbsidenceConlrol It R' 1
Geothermal(Closed Laop), OTraeer s0a SY .ini""hciadrtinl'uiafCeet:Rl+ua'u:-."_-`=�wur='=;•
_Geothnsmal(Aeating/Coolin Rotund) Ocher ex nunder#21 Remarks EOM To Orson x adtnMdnttr,wtt/sask ,�ac.
R. O R
4.Date Well(s)Completed: well 1DM Q n r •
5a.Well Location: 40R
FacltyfOwnaNamc // Ftcai/b11n8(ifiliDDticabb) `' tc D' �_
a,OtC �n ftG
n yilcar and T� a to n
ph ;
jw
Couow Pmel Idemiticauon No.(PIN)
5b.Latitude and lottgbade to degreeslmiantes/uxonds or decimal degrees: J
(ifwell field,one Woo sufde t) 2L Certification: AU
35.ao7771 N •- 8!•of+9So,3 w � � �
6 hk
Is(are)The well(s) Permanent or OTemporary Sigownavo enilledWellConeactor Date
yyy��[ By suing dun jbm f Aonby eaa)y char the vWk)war 1ti'm)muawred ih occosdwto
7.Is ills a repale to ao existing well: (3Yes or No with 1JW NCAC 02C.0100 or 15A NCAC 02C.0200 Woof Coenntcdon Smadardt and that a
(/this is a rep*.fill ow Anami vdl commc loalxfatatariatt mrd�e'p M the nahoo ofthe copy offt eveordha beenprovW4 to the well mercer.
repair under#21 mamrlr section or on the bast afrMsfatau. 23.Site diagram or additional well detads:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may ust the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBBR of was construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRIIC.TIM
9.Total troll depth below land surface: O 0 00 00 24a, For All Wells: Submit this form wilhin 30 days of completion of well
For molaplewe0s list aff&pduriildifferrm(euvwls-I(VW*•mmul2®100') construction to thefollatving:
10.Static water level blow top of cafe. S7 3 _(It.) Dlvislon of Water Resources,Information Procesdug Un%
#vwarleeel uabat ame itse"+^ 1617.Mail Service Cebtey Raleigh,NC 27699-1617
IL Borehole diameter. 0 y'—- on.) 24h.For inleetlon Wells: in xddition to sending die fsmnto the address in 24a
\ f„y,l above,also submit one copy of this fbna within 30 days of completion of well
12.WeB consfruelion method; T"` construction to the following:
(ia=gu,aauy,cable,duct push,eta)
Division of Water Retoaretti,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Centel,Balcigh,NC 27699-1636
r
132.Yield(gpm) �• _Method of test: . 24c.For Water Supply&Inlecdon Weals: In addition to sending the form to
the addres(es)above, also submit one copy of this form within 30 days of
13b,Disinfection type: rr Amount. completion of well construction Ito the county health depamnent of the county
where eanglrueted.
Form Gw-1 North CmatimDepanmeat afEdvin ameanl Quality-Divisionof Wow Rcsomees Raised 2-22-2016