GW1-2022-06196_Well Construction - GW1_20220620

Jan. B. ZUIU IU:7UAM tnV, Health NO. 0 11 1 r• 1
WELL CONSTRUCTION RECORD!GW 1) For Internal Use Only:
1.W.1 Contracto I I11forma(l0 •// `
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i FROM I TO DIA lETER TE IMES9 MATERIAL
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2.Well construction Pa'mit S., I ft. rt. ln.
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• n. R In.
3.Well Use(eheekwell use): _ _"• ---.-•--"- �-
WaterSupp►y1weU: FROM TO n CR SLOT T t sSs MATERinL
_Ag[iCU1N®1 ,[}M tctpel/pnbllC 0 R ft. 9O•
Geothermal(ReatinglCeoling Supply) �(xestdential Water Supply(single) ft. R i°
_IndushiaUCommcrCidl DResidentialWster Supply(sha[ad) 1g_[iNOUT:': '--. ' :�- ri '=
I tom To - MATEnrAL S�rPr.►CEA1 MMOD&AMOUNT
_IrFintion y {.,�y•- 7,r R. tt. ,�a • f1Ji� - .•i t1L
iYon-Water Supply WcU: :` �..�,�°��.s �,✓ m, ?"� �c .
Monitoring dRecavery n. R.
Injectlon Well: �II I�I Wn' l4 fr.
A uifefRce o GrmmdtiveteYEt.2A2022
q � d z���lclta�lEtrae • ._.-raster_=._-F��-:-:�::�._.y. _..:,:�--•-:ram '
ufcrS and Recovery [_�S nn ap��C rttosr To MATEtt111I. Etiteucci~terrtntsrxon
- �l t�8e i�rlt'Gtr$tm it PrL-03GVI;tg RFi n R
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4crimentalTechnology 13SubsideltceControl tG
Geothamat(Closed Ioop). Tracer ;�a� �3tjG aiFaeLaddTtiortiiicbeet:it:4huiai'a" �`='=-
PROM TO DESCHnrMN color,6ardna%njjtEc to ek.
_Geothamal(AeafiopJConlingReNm Other >aiquaderN2LRematks R 7 R _•_ / SOS
4.bate Wells)Completed: Well=1 7O h I `�!r
sa.Well Locatiom It: G -e- e-ft e
/
SG S f 0 tt.
FacdirylOtwet Tfame PleAi(Y IDt!(itiipplieabm)
LIAl
Physical Address,C y,add Zip if..
Couaty PatealldmhifialiaatJo.(Pit3)
5b.Latitude and longitude in degrcediniouteslseconds or dedmal degrees:
(ifwall fletd•one lu tansi suffie 111) 22.Certifiea6on: -1719
"
6.is(Are)lhewell(s)iOr"mauent or [Temporary
9igoattaeo trti6edWeRCmmactor Dato
om'
By t;Eaing hiss jvmt.I hereby eerU�•rhm the h.ell(s)h+,os{t„ereJ rahunuared m aavrdnnca
7.Is this a repalf to ao existing weu: 13Yts or nNa with ISA ACtC 02C.0100 or 13rt NCIC 01C.0200 Well CahtrNGtaa StMePh t and that a
(/r6islsarspaP.JillwaImawtwdfeaatruaonfnfaraationmrderphm the nature ofrhs copy vJthRovC0Mhublenproildidtodwire0oxsrer.
upair under 021 mnmrir atuton arontAe haekvfr;drfarra 23_Site diagram or additional--ve11 delalls:
S.For GeoprobelDPY or Closed•Loop Geothrrmal We11s having the same You may use tine bacL of this page to provide additiarad%veil site details or Nvell
construction,only 1 GW 1 is needed.Indicate TOTAL,NUMBER of v lls tronsttncGondetaits.You may also attach additional pages if necessary.
drilled SMNUTTAL wsrj I(TIONS
9.Total well depth below landsurface: ;L 111) 24a. For All Wells: Submit ibis fomt N% tia 30 days of completion of well
pay mnluplexdtsl&ralldepdt+;Jdfjerun(emmple.3(a)700•and2�10U) consnuctian to the fallowing:
10.Static water level below top ofcasing: �G (A-) Division of Water Resources,Info rmatlon Practising Unit,
ljxarerletof tr above cariug use"+'• 161713ai1 Service Cettters Raleigh,NC 27699-1611
11,Borehole diameter-. 246.For inlecton Welml in addition to sending the farutto the address in Na
�) ( Y'I above,also submit one copy of ibis fbtm within 30 days of completion of well
12.Well construction method: `i u construction io the following
(U.sugar.rotary.cable•timer pmb.eta)
DinisionatW9ter AdoarceB,Underground Injeettan Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636,Nbil Service Centel•,Raleigh,NC 276991636
L
13a Yield(rpm) Method of tesC 24e.For Water Supply db Inleetton WcUs: To addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 f Amount: CG completion of%all construction to the county health depanment of the county
where contacted.
Form Gw-1 Norris Cmulbm ncpw=eA1 OfEdVimmneaml QueT,ry-Division of Water Rcsomces Revised 2-22-2016