GW1-2022-03439_Well Construction - GW1_20220318

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
IL WATERZONES f
Well Contra ttXb Name FROM D1SCRIF1ION
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NC Well Contract�oe Number �J 3 n Jam$ ft. G Q�
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V.2n 4 E�1`s [ _it J l r; .`h cr. 1MM TO MARMER
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2.Wet Construction Permit#:�Y- RHOM m I DIAIMM I MNWMMS I X&MUUAL
zisranop�icnatsuru�trsda�pvmitf(ce urG cams?:stag parrm►a�etch n n nz
3.Well Use(cbc&wet use): tt n :n.
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FROM TO DTAMEIER SWrSDB THICBPFSS MA7IBIAL
0 afi / (5R l water Supply(single)DResideobal water Supply(shared) IL GROM
FRM To MATERIAL CJs YrMMOD&AM UW
Non-Water Supply WdL• Q n IL
OM-buri-91 ❑Recovery 3 n �.p & 1 i1 11�
7mjeefion well:
ft. n
Recharge OCmoundwater R.'ediation
1''' 1A SAMA=AVRL PACK a
"ifer Storage and Recovery [3Sali.&y Barrie[ FROM in MATERIAL EP ACE MMINEMaoD
JAquifer Test M IL
&petimenw Technology E)SOMMence Control
Gcothermal(Qosed Loop) EITrarer zit DRU LnvG 1.oG .ttieh aa�Gonatateets:r
G-*c—al(H-b*Coo1m&Remm). Other(explam under fi21 Rematlrs) r1toM To D UM mh,tuft—s w-& - smq mac.
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4.Date Wdl(s)Completed: WetlM3 On l
Sa.Well Location: ,: ,.: ,
rrer "Ws . 16 "VX0"A Met 5 ,M—
F�i6ty/ovracrxame F—TgID#(if%,bcabk) _ ewe
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�,l°I`� aYi'�� t�'E `tbt�(�Q_ �� -��✓'��G �1537 n R
`PhysiealA tfess,UM and Zip '" R 1
V OIXI C F� ®�iO O O(7 2L REMARKS
co-dy Pamc11dcn ifio4onNo_(PIIl)
Sh.Latitude and longitude in deg;eea/minutes/seconds or decimal degrees:
(lf--We�t field,ODC-�la,�l/1�IS Suffice l) 22.Certification:
L .• , - -.
2 J %1 1 1V �o � �( � W 03 lit
&b(are)the well(s)JElPermanent or Temporary Signahne of C4tified Well C&wadar Irax
By signing this form.1 hereby cesafy that the w fl(s)was(were)constructed to aeoondance
7.Is this a repair to an existing well: ❑Yes or MNo with 15A NCAC 02C.0100 or 15ANCAC 02C:0200 W.H C.1racaan standards and that a
ff this is a repair,fill oat bm m wem conptretim bformattoa and explain the mom ofthe copy of#-record has been provided to the well owner.
rrpair under#2I srmarks seNion orate the beset of thfsfarm. Yousm use the or additional of tots well details-.-.
,.: � aim
8.For Geol""PT or Closed-Loop Geothermal Wells having the same ay. page. provide additional well site details or well
constrtuxiom.only 1 GW-1 is needed. Indicate TOTAL N[IMBIIt of wells construction detuls. You may also attach additional k... pages if
necessary
SUBMffTAL INSTRUCTIONS
9.Total well depth below land surface: OS (IL) 24a-For'All Wells: Submit this form within 30 days of completion of well
For mrtltiple wells'list611 depths tfdrfferent(e�amotp/s-3(t�200'and 2(cI00) construction to the following:
10.Static water level below top of casing: 3c (tl.) Division of Water Resources,Information Processing Unit,
Ifwwer.kvd is above cwft am"+"
. .__..: .. _. . . . _-.... .._... ._.._ :. _ .... . . 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Injection Wells: In addition to sending the form to the address in 24w
above.also submit one copy of this;form within 30 days of completion of well
12.Well consumcdon method: Al(Z f`->0T constrktion to the following:_.,
(Le:eager.-tuy,cable.direct 1�etc)
ONLY: Division,of Water Resomtcs,Underground Injection Control Program,
FOR WATF -
dt SQPPLY WF LS ..,_ _ . . ca
1ti36 Marl Serve Cesb�,Raleigh,NC 27t7991636
13a.Yield(gpm) Method of test: 1 24e.For Wafer Sim W&Iniectiaiv Wets In add6 to sending the fame to
the addtas(es)above, also submit' copy of this t arm with 30 days of
13bh DMWr,!ction type: . Or i �' Amount: \ t)Z. completion of well won to the.county hearth dpwanent of the county
whale wed
l ormGW-1 Nit&Cmobna Depart mt ofEavrtaon mmW Qwday-Dmmon of Water Remw= Revised 2-22 2016 i