GW1-2022-04309_Well Construction - GW1_20220428

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor Inf tiop:
14 WATER ZONES
Well Contractor Name FROM 70 �DESCRrION
fc /p0 ft. s
ft &
NC Well Contractor on Number I&OUTER.—..6 for.�ntti easedw�ells`OR L1NER d
r FROM TO DIAMETER iHIClINE55 MATERIAL
s2 ft & in
Company Name .16-INNEEGGA.SIIVG OICTUBUZ
...
2.Well CODstrnction Permit#: FROM I TO I DIAM9ETMZ!Rl TMCIOWSS I MATERIAL
List all applicable well construmon permits(r.e.CX,Comfy.State.Variance.eta) R. ft in
3.Well Use(check well use): S & m
IC—&-nal(HeatingAqooli
ter Supply Well 3`I L'SCREEN .:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultural DMunicipaUPublic 0 & it in.;
eothermal(Heating(Cooling Supply) E3Residential Water Supply(single) ft & hL
dustrial/Commercial QResidential Water Supply(shared)
,�GRUiTi
Irrigation FROM 7•O MATERIAL EMPLACE M METROD&AMOUr r
n-Water Supply Well ei v l
onitoring Recovery fL &
ectior.Well: ft R
quifer Recharge ©GroundWaterRemediation19.SANDlGBAVEL`PAEHquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENTME7HODquifer Test' 13Stormwater Drainagexperimental Technology 13Subsidence Control i< &
eothermal(Closed Loop) Tracer) Other( lain under#21 Remarks) FROM TO D r.hardness.sonhock qM IM am ea
R v &
4.Date Well(s)Completed: a.1 Well ID#
51L Well Location: ft. fL
� & ft.
i le a /l ✓GOP
Faeibry-rOwne;Name�� � � Facility ID#(if. plicable) R ft
& ft.
Physical City and Zap & &
AY
des 7«^ ..2LREMARSS
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat4ong is ai>Feiect) 22.Certification:
N W �7
6.Is(&-)the wells) Permanent or Temporary Signature of Certified Well Contractor Due
By signing this form,I hereby certify that the well(s)was(were)constructed m accordance
7.Is this a repair to an existing well: ©Yes or �N. with 15A NCAC 02C.0100 or MA NCAC 02C.0100 Well Construction Srardards and chat a
!f this is a repair Jtfl our kr�wr we!constrvctton info mftion and erPla6t t'u romure of the -m ofthis record has bees provided to the well owner.
repair under 921 remind s secdon or on the back of this form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS',
9.Total well depth below land surface: (fL) 24a. For All Well Submit this form within 30 days of completion of well
For mdtiple wells list all depths if4r++(—ple-3 0 and 1 0 construction to the following:
10.Static water level below top of casing: (N Division of Water Resources,Information Processing Unit,
!f water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the farm to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f d /11 1
construction to the following:
(i.e.auger,rotary.cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"4636 �
13s.Yield(gpm) / t/ Method of test: /y 24c.For Water Smomly&Injection Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / H— Amount: completion of well construction io the county health department of the county
where constructed. i
Form GW-1 North Carolina Depatanent of Environmental Quality-Division of Water Resources Revised 2-22-2016

� `
�v