GW1-2022-03798_Well Construction - GW1_20220404

Jan. 29. 2018 10:58AM Env. Health $ ,�`' �" ° No•"6711 K 1
WELL CONSTRUCTIdN RECORD(GW-1) For Internal Use Only:
1:Mc2druform'd / //_ /� •• PROM TO DFSCRWMN -
WellConlractorName [4 1 00tL
NC Well Comse orCertificetion Nvmber R1"UTEWCASMG'ffilt'ATIMa9irweIIs'Ott];IlVEIt
Rn af-S I 7
`i FROM TO' DIAMETER 7RICItNFSS MATERML
(� _fe
R. $rL '° SD UG
Compan a- —:: o—
���+� ;1 INNER.CASIYG:OITTt1niNGi_.._therivat:dosSd:toa'w,!mt�p:•�r:-ct'�.:—=<
2.Will Construction Permit#:, FROM I To I 01ANIttTM I TRICIMM IMATFnur
/,lrrallapplicadrexelremutnrenonpemdrt(1.e.IIIC•Corry,Srate,variance,ere.) R. R. �•
3.Well Use(ebeckwell use): p�pyft. h. �•
eJ.Z.litiJWl.Ka��Y�sx-'n^:.a::i y.•t�r L 1._•.`•..`,J �w....••u�.�'��P:�t ?�.........."w
i;rrigaticn
atersupplyWell! FROM 70 ,
DiAMET , SLOTstME n.1.I rt MAAgricultural Q :cipaUPnblicGeothermal(ReatinglCooling Supply) Residential Water Supply(single) R it.ndustsial/Comrncneial dResideutialWater3upply(shatcd) 7s ON0UT' .`.w;:'- = e^ "y - -FROM 1110 MATEMAL. I MUCEMEN_C NEMOD&AMOUNT•
Von-Water Supply Wall: Q a. $ n I,' `►N t
- Monitoring Recovery R. rr.
_ Aquifer Recharge QGraundimterRemediation
19:"9A'ND1GPAVEGPXCK Fiffi lid0l, -. a,;_::�;��" ,•' - _
Aquifer Storage and Recovery DSalinity Barrier nm.I TO MATERML EMPLACChrtdtPTMrrAOD
_. AquifcrTest -[)StormwaterDrainageft
R
Experimental Technology OSubsidence Control ft• h
Oco thermal(Closed Loop): �]Ttacer s2Q1i I TGIt'1G iifai}iaadl'ttoiuiii6ee�[fhe�Easi '=_`-.•••'= -:mow
:. FROhf OFSCHD?IIDN alonlurdntsasolFrork iaL err.
_t'lcothermal(floating/CooNj Return Outer(explain under#21 Remarks R TOR.
eA
4.Date Well(s)Completed: "3 n f1 well ID g >r -�
5a.well Loaatiom / ft. 1t: ,
C70n@
FaciliVOwneeMama Peclityn)9(if ippticab1p) h ft.
P}rysieal Addmss,City, d Zi ` �S C. lG a n
r(;oualy Pnsralldeatificaoda No.(PIN)
Sh.Latitude and lobgitude in degreeslmtouteslseeonds or decimal degrees: Y' ) '^,` �l t
(irwell HOW,ona ladlong is sufficient) 22.Certiricatian: ,Er"
9igaanueo enifiedWeIlConttsctor D
' b.Is(are)Ibewel[(s) Permaaeat or [TemporWe
i
By signing di;s form I hereby eerglj that rhe wall(s)war(wre)co:rtmeted bJ dccordhace
7.IS this a repair to aD existing weft: ❑Yes or with 114 XNC 02C.0100 or IJA NCAC 02C.0200 Well Conamarton Srmklar&and that a
(lulus rs a rapat>:ftfl wn known wet!ednttruefioh lnfar8,ariei,arrd atplabr rhe aalrrre of the copyofthis racoxihos beenpror tded to{he trell owner:
repair un&r#2l remarks rerun or as rhe baekofrMsfarm 23.Site diagram or additional well alelalLS:
kFor Geopiobe/DPT ar Closed-Loop Ceothermal Wells having the same You may use the beck of this page to provide additional well site details or well-
donsWelion,only l GW 1 is needed. Indicate TOTAL,NUMRBR of wells constiuctiondetails.You may also attach additional pages ifnecessmy.
drilled drilledL., SUBNHTTALINSM C71�NS,
9.Total well depth below lied surface: A) 24e. For All Wells: Submit this fora within 30 days of completion of well
Forrumple.Wc1k fir#arl drpAg if&jerenr(kza*,1-3@200'anndd2®100•) construction to the following.
10.Stodc hater level below top of easing: �7 __OL) Division of Water Resources,Information Processlug Unit,
q'varerrevel tsaboveorrbig use"+ 1617 Mail Service Cehter,Raleigh,NC 27699-1617
31.Borehole diameter. . (in.) 24b•For Inlecilon Wellst in addition to sending the faun to the address in 24a
above,also submit one copy of this lbtm within 30 days of completion of well
12.Well construction method: 0 Y construction to the following: f
(i.m sager,rotary,cable,d mi ptub,cto.)
Division of Water Resoorces,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Canter,Raleigb,NC 27699-1636
13a.Yield 0M) Method of test. / 24e.For Water Supply&Inlecdon Wells: To addition to sending the fotn to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: Gt completion of well constmction to the county health department of the county
where constructed.
FomnGW-1 NoaCa"mDelmutmeatdM irawentalQuality-DivisionofWoterRcsoMM Revised2-22-2016'