GW1-2022-05440_Well Construction - GW1_20220607

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
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NC Wdi Coamiffir Certification Numbs :.: — -- +
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L Wen Construction Perfniff, FROM TODJAM4'fRR TRiChmM I MATERUL
/1pa11 mLle well emuweaon pemrtu(l e.UIC,C&MW.SSme,Vadaaee,ac) rt. ft. to
3.Well Use(cheektwn use): n
Water Supply Well! �12•:�s�g�a:<:.�y;�;- _ =-`�.a.. _ —�.Q�<=-�-
rRA 40 �aEttuL
Agricultural QMwicipallFablic 0 R. 2 fo•i
Geothermal(8eatin5/Cooling Supply) ffillgldential Water Supply(siiioe) IL R to
_IndushWCommcrcial ORasideatial Water Supply shered
lion IMMI 1 TO I MAURIALAMOURr
Non.waier supply Well: I R ra
i
Moaitming ❑Rewvery R. ft.
Injection Wen:
- Aquifef RecN%c [)Groundwater Remediation -
7GReS?ilSffPACIC' -._.•ti@+iUle-�-=,r:_.,-:�:.�-`..�...W •.'.•,-.--'
Aqu&Stoop and Recovery DSalinityBatrier FROM I TO MA I.iC>vhtENrMUMOD~r
AquifcrTest •r3Stwmwater Dteimge & IG
Experimental Technology Subsidence Control 2 rt
Geothermal(Closed Loup) DTrwer 72 p �1�lG■ira�i eadItiobsibliieestte«a'iis'
Geodternr0l(Heating/Conl ag Rerun Otter lain urhderti2l Rematks Mom To OfSCRlrrrod:alo46ardnear.setlhxk, �� i au.
c
J.Date Well(s)Completcil—/La Well ma n R' G e
5a.Well Location: / r 0` o S
�1,�/�� �/'1"� Y *07 7 � R. ft.
v n s
Fsa7iry10wnerNarne FeeaiNtD�(ifiipplicable) EL .
1 0 7 2022 .
P6yai�ova c�.:ad� a n.
Co-ly Paaellden0artiaaNa(PIN)
5h.Latitude and loWlude in degrsedinioutes/secouds or decimal degrees: /
(iPnen field one tallog is wMaieat) 22 CertiGcatiao: �Y7 "
?<. 3.2 G 7 yf N" 9Z. 2 V// 1-2 w
6.B(are)the well(a) Permenent or QTemporary Sigmas agetnifled won eouncror i Date
ley s gmng 111:1wn I hdrdby rer*rear the vep(s)%w(rrm)eoneoueted m amManae
7.Ia this a repair to an exlating Weir: QYes or Ono .415AMCAC 02C.0100 or 15A AUC 02C.0200 Welt Coea»ratea Staattor*and that o
((rhis is a Neat,JW out inowewelt uatr uuionhfa macron axderplam rhenahrro ofthe cW ofihis amid hos bddnprom Mro the hreffowner.
rep*under 021 r ork salon ar on the had of ft foraL
23.Sire diagram or additionAr well de1A115:
B.For GeoprobdDPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or Weil
construction,only 1 GW-I is needed.Indicate TOTAL,MMUR of welle constmct on details.You may also attach additional pagm if necessary.
drilled f SUDMITTAL INSTRUCTIONS
9.Total well depth below brad surface: � ti✓ (0 248. For,All Wells: Submit this form witi in 30 days of completion of well
For matiple worts 1w oil depdu,fdffi; kznr(600nple.3(a2tltl'and2@10)) construction to the followittg:
M Static water level below top of casing: ✓ _(R) Division of Water Resources.InformAtton Processing Unit,
/fwmer local is above aura&ace"+" 1617 Msil ScrMce Cchler,RAlelgly NC 2709-1617
11.lanhole diameter. Z44 (tit.) 24b.For Inleetlon\dells; In addition to satdatg the farm to the address in 24a
���ar above,also submit one copy of this Than within 30 days of completion of Volt
12.Well construction method:
(i r.dugs,navy cable,drteet puth.eto.) construction to the following;
Division of Water Resources,Uhdetground Injeedon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel•,Raleigh,NC 27699-1636
13a.Yield(gpin) Method of test.- , 24e.For Water Supply&Injection:Wells: In addition to sending the form to
the addrcss(es)above, aim submit one copy of this form within 30 days of
13b.Disinfection type: Amounr completion of well construction to the comity health department of the county
where constructed.
FotmGW-1 North C®thmDgmtmeat otEavimomenml Quelicy-Division of%tefRerouree� Revisod 2-22 2016'
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