GW1-2022-03689_Well Construction - GW1_20220321

Jan. 29. 2018 10:58AM Env. Health No. 6711 P. 1 MEAN NOW
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NO
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.W I Contra f Inform", `
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Wdl Contractor Name; FROM TO DESCRIPTION....
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NC Well Coalme Cefti6cauon Number .1t OUTZTrCASIN5 t6irdfldif4eSeil=weIls:OR`-LlMM f it upI"_M' ee_�:jr°"°,8.'',"•;
FROM TO DIAMM0 THICKNESS MATER�IL
o��rr� l.l�c�ll � � �er�1aC� R. R. � is —
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{ �a II � ::I IIVN&R'.CASIY(i.OR'TG1A1PfCy? ..theriuin;ctiaed-t'n u.�+�s;.::da�-:-k=...-_;:
2.Well Construction permit#: X0 FROM TO DJAMMIt TMCXgM I MAURLILL
l frrall opplicabfe irdl tonrrnurion petade(Le.WC.Cmmty,Srats.Variance.etc.) R, tr. to.
3.Well Use(check well use):
fIirrigation
ter Supply Wen!
FROM YO DIAMET R ZB SLOTSI THICKNESS MATERIAL
gricultnral QMunicipsypublie 0 R. ft.
eothermal(Reating/Cooling Supply) C)Residential Water Supply(single) ft. fL In•dustrieUCommacial 13Resideatial Water Supply(shared}} FROM TO MAT¢RIAL L.IIPIACLMEfff.YlVMD AMOUNT
Non-Water Supply Well- O R. tr.
Monitoring ORecovery R. ft
Injection well:
h. R,
Aquifof Recharge [']Groundwater Remedietion _•__
I9:SiT4V115FAVELFACIr' fa lieatile'r.__-::•_� a<v-•_C;;.�"T- 3;
Aquifer Storage and Recovery QSAirrilyllartier FRO51 TO I MAUTUL (ACURNIMUNOD
_. Aquifer Test C)StormwettrDrainage n• f
Experimental Technology ]Subsidence Control rL ft.
Geothermal(Closed Loop). dTraeer 2QD Ifih*G•]AGE ei5el;addWd-)iii.;N4Er.Iflre'cisisi
_ Geothermal gl f'g FROM O OfSC WFI N color,heNneshsollfrock y `oinjim tic.)
(Hentin Cooliri Rearm Other(explain under Remstks R R
NUIA
4.Date Well(s)Completed: 3 Wei 1D# 76 h 0 rt a
Sa.Well Location ova It, O ft. ae,.�
A&
FacilivownefName Facility IDA(ifiypliceble) ft.ft. V n. _
A
Physical Add7i.City.and Zip N,L. BOl/i U 2 ff.
C w PamAl16-1-fiearion No.(PIN)
56.Latitude and lohgitnde in degrees/minutes/seconds or dedmatdegrees: j C •� �,����;.,';,';;;� ,•„ _ _.
(ifwell field,one IarRang is sufficient) 21 Certification: �V p
35. 3/ 0 9S/ N — SI. �9��l► W ,A 1 oa _i 3 1 S .)L a-
6.Is(Are)The ivell(s)loPermanent or ElTemporary 9igmnae atZatified Well Contractor Date
By iigrdng this form,I hereby eerfgy rhos the>.e/l(s)r,as(ae►e)cwulmeted m accordaaca
7.Is this a repair to so existing well: Yes or o with 15A NC4C 01C.0100 or IJA NCAC 02C.0200 Well Coartnimlon Sfaiidor is and that a
(!this fS a rvpah;J8l ord ktown wdl eonruuaioh mfareurtion erplaf i the naftme ofthe cPpyofrhu—td hoe beenprosgded ro the W110WINA
repair under a21 remark section ar on the bast 0jrddSform.
23.Site diagram or additional well details:
&For Geoprobt/DPT or Closed-Loop(•eothermal Wells having the some You may use the back of this page to provide additional moil site details or well
construction,only 1 GW-1 is needed. lndieato TOTAL,NUMBER of wogs construction details. You may also attach additional pages if limenary.
drilled: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓ �O 00 240, For All Wells. Submit this form widlin 30 days of completion of well
For mdnpls week list all deptlu fdi&enr(aan pfe.1@200�•and 22@1001) construction to the following:
10,Static tYater ICVcI below top of casing: 11 10- (ft.) Division of Water Resources,information Processing Unit
(fwarer level Is above cnsftr$tare"+" 1617 Mail Servlee Cehter,Raleigh,NC 276994617
11•Borehole diameter:12.Well construction method: A0(fit)
24b.For Inteciion Wells: In addition to sending the farm to the address in 24n
/ r)�(( above,also submit one copy of this fowl within 30 days of completion of well
`�•
(U.auger•ro1uy,table,(rmt puck eto.) construction to rite following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cenid.Raleigh,NC 27699-1636
13s.Yield(gpnr) 'rV1 to Method of test: . r24 For Water SUPDty&Inlettioe Wells. In addition to sending the formto
eddress(es)above, also submit;one copy of this form within 30 days of
13b.Disinfection type: Amount: 4 completion of well construction to tho county health department of the county
when ConslNGttd.
FormGW-1 North CarolionDepanmeat afEaviroameanl Quality-Division of Water Resources ReAsed2 22-2016