GW1-2022-06801_Well Construction - GW1_20220715

Jan.'29. 2018 10:58AM Env. Health No. 6711 P. 1
WELL CONSTRUCTION RECORD LOW-1) F.or Internal Use Only: !
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1.W 1 Cootracto IDtOrmatlo
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WdlContractorName Aim To DESCRIPTION
NC ell Coatracof Cettifirauon Number y D it. Al.S ft' S� G
' OI11E1rCASIbiG:f6irinidtFeiiaid>"vvclls:Ok1;1NElt f- 'Iii5r0lE .:.et''�R:"
FROM I TO DIAMETER I THICKNESS MATERIAL
ft. 1 . k-d PVC;
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.16INNERCAS1PIii`U1tTUDIIKC?"'1hiWnidl:do"iid=roc'.�+ +tst�r=i'' '_
2.Well Construction permit#: FROM I To I 01AMRr'MR THICID1Et.9 MATEtWL
/,{garlapplirnblewdltmumreNo7rpemrturya.WC,Cormry.Smre.Variance.etc)' h in.
3.Well Use(checklvell use):
jAgricultural
terSupplyWell: DIAMETER iaLOTSIZE Tn[CKNPSS MATERIAL
QMunicipalftblic 0 ft. it,eothermal(HeatingfCooling Supply) sidenGal Water Supply(single) n ILdustrial/Commerciai [3Resideatial Water Supply(shared)ri lion FROM TO~ MATERIAL . UIPIACEMERTMEMOD&AMOUNT
Non.Waier Supply Wall tr. Q rr. ,ni I' t.N r VA nt,
Monitoring ❑Recavery D. ft. 1
i;
ICG
ection Well: h ft.
quifer Recharge QGroundwater Remediation'
quifer$torage and Recovery DSalinityBarrier 4'RO.'tt TO M IAL ATER EMPIACI±AWbUrHOD
quiferTest [)StormwaterDrainagexperimental Technology Subsidence Control toC: l"a"ah'ecthermal(Closed Loop) C)Tmcer s zOrp IING3 b aiaddltic)—mi:ebieHT.�` FROM - TO oucawrloY taeathcmraI(Heating/C41i4gRethm other ex lainunder#21Remarks
4.Dart Well(s)Completed: °� Well IN
Sa.Well Locations
�QGFd llal-l-eZ J 7!�rol,?7 ,�
Facl (iw We<Name Faeli(ylDlf(if 1pylicabls) 'i' a "t a im
Physical Address,City,-aa p fa M " 0
r. 9
County Pntcel identificarian No.(PIN) cf3��s I}t�i'�( [Air,
—
' � �1illlL"�i:9 �L7
Sh.Latitude and lougitude in degreeslminutestseconds or decimal degrees: c
(irwell field,ON lad long is sufficient) 21 Certification. ���//
6.Is(are)The well(s)JOPermenent or OTemporary Sipanaeo enifiedWellCounctor Dato
By rigdag this fart{I hereby eera)y thar the irell(s)um(mere)corutercred h)acconlonce
7.Is This a repair to oo a fisting well: E)Yes or ONo wid,11I NCAC 02C.0100 or l3A NCAC 02C.0200 WB11 CoArinwrion Markley&and that a
((this Is or repaM fNl out ltrown wdt eaatrrucrioa hfarmarion and erploDt the naatre afthe eepy ofrhrs eve id has beenpror9de4 ro;fhewell owner.
repmr ursder 021 immrlr section or on the backofrhlsform..
21 Site diagram or additional well details:
8.For,GeoprobdDPT or Closed-Loop Geothermal Wells having the some You maymso the beck of this page,to provide additional wsli site details or well
construction,only I GW-1 is needed. hidicato TOTAL NUMBBR ofwelis consruction details.You may also'agach additional pages if necessary.
drilled: SMfiTTALINSTRUCT ONS'
9,Total well depth below land surface: (Ct.}
Farm,daplewerh60 all AwAs;140renr(er-Ple:3@21V'akd2&V) cons For All Wells; Submit this'form witoiH 30 days of completion of wall
construction to the following:
10.Static hater level below top o[easiDg: (ft.) Division of Water Resources,Information Processing Unit
ffwarerlevel ttabaecaring use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.— _(In.) yob,For Inleellon Wells: In Addition to sending the fbnuio the address in z4a
above,also submit one copy of ills ibml wilhin 30 days of completion of well
12.Well c ay.cable.
.c method: �� _ N 1 construction to the following:
(.a eager,mtary,cable,dues pu.:i�eta) � I
Division of Wafer Resources,Underground Injeedon Control Program,
FOR WATER SUPPLY WELLS ONLY: %36 Mail Service Center,Raleigh,NC 27699-1636
t.
13a.Yield(gym) G Method of test: 24e.For Water 9unnly&Iniceltori Wefis: In addition'to sending the form to
ft address(es)obove, also submit one-copy of ibis form within 30 days of
i3b.Disinfection type: Amount. completion of weft construction to the county health depamnent of the county
where constructed.
FormGW-1 Nesth C=fizmDq=tment ofFAvimmaearal Quality-Division of Water Rcsomeesi Revisod 2 22-201d: