GW1-2022-03459_Well Construction - GW1_20220323

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WELL CONSTRUCTION RECORD_ GW-1 Fr Intemat Use Only:
1.Well Contractor Information:
14. ATERZONES
5 ).�j�r 1�� 'mil 1 A t y➢2 ` n TO DESCRIPTION
FR M
Well CoauactorNsmc
ft
1
NC Well Contractor CenificationNnmbcr 1S. I1TER CASING(for mold-caved wells OR
� M Y0 DIAMETER
16. CAM OItTUB G(e°tfio:malTffiGKNEss
CompanyName D � MATERIAL
ER M TO
2.Well construction Permit#: % ft. in
List all applimble,wll contraction permits(ie U1C,Coma},Stare,Yariarsce,etc.) fL in.
3.Well Use(check well use): 17 CREEN. � gq blATERlAL
Water Supply Well: MR,
M TO DIAMEr R
fL in.
Agricultural �IvlunicipallPublic it
Geothermal(geatinglCooling Supply)
esidenfial Water Supply(single) ft
Indushrial/Commercial Residential Water Supply(sbazed) 18 GROUT . , METHOD&nvloVNr
M TO t
lrriMation M R' s
Non-Water Supply Well: ft ic.
Monitoring Recovery
Injection Well:
Aquifer Recharge 1303mundwaterRemediation S /Ggpy ,PdCK if lieable
a/r To MATERIAL
' Aquifer Storage and Recovery �Salinity Barrier & ft.
Aquifer Test (3Stormwater Drainage
Exp �Subsidenee Control
erimental Technology
S. ft
2 DRILLINtG LOG attach additional sheets if
Geothermal(Closed Loop) 13TMcer M To DESSMMTION wtor,hmr8auxs,sorurm k .Da etG
Geothermal(He ating/CooIing Return) Other(explain under#21 Remmks) ft. 6 ft. ro
4.Date Well(s)Completed: Well IDp 1 IL e
ffi �
59.Well Location: fL ft.
3 M >fw
gacility/ Name Facility IM(Napplicable) R.
.►- ` E- C.
Physical S.City,and Zip I R1
Parcel IdentificatiouNo.(M)
County
Sb.Latitude and longitude in degreeslminutesfseconds or decimal degrees: 2 .Certification:
(ifwell field,one latilong is sufficient) s 6 0
N W �
r
crt ficd Well Contractor6.Is(are)the well(s) Permanent or Temporary is fora,,1 h®eby cert that the tivell(s was(were)corestracted in accordance
C 02C.0100 or 15A NCiiCO2C.0200 Well Constrsrctiors Standardsanddrata7.IS this a repair to an existing Well: Yes Or 0 ecord has been providedto the well owner.
Ifthis is a repair,fiII tint knon�t well constructoninfor9ie nature of the
repoir=der021 remarkv section or an the back ofthisform- gram or additionalwell details:se the back of this page to gravid!additional well site details or well
8.For Geoprobe/DPT or Closed-Loop:GeothermalWellshavingthesame details.You may also attach additional pages if necessary-
constmctionc only 1 GW-1 is needed.Indicate TOTAL NUMBED ofwells AL MSTRUCTIONS
drilled: 1 +� of eom lotion of well
9.Total well depth below land surface:, (fL) 4 For All Wells: Submit this form within 30 days P
For multiple wells list all depths ifdiffereni(example-3(a)2ool mud 2Q1601Co tntetiou to the following:
yy (ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top Of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing use +"
id'J (in} b.For Ini�Wells: Tt►addition to sending the form to the address in 24a
IL Borehole diameter-.
t ve,also submit one copy of this form within 30 days of completion of well
go truction to the following:
(Le Well construction(able,dMtp b,etc-)
(Le-auger,rotarvy,, Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Mclgh,NC 276991636
FOR WATER SUPPLY WELLS ONLY: n
G For Water Snr+nly&Iniectioa Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: address(es)to above, also submit one copy of this fog wtthm 30 days Of
completion of welt construction to the county health department of the county
Amount: R
sa, n:.:nfnriinn tYDC. ere constructed.