GW1-2022-07232_Well Construction - GW1_20220805

WELL CONSTRUCTION RECORB CGW 1) ' For Internet Use only..
A-Wen 0antmetorbiormation:
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ft. fi; In. S CompanyName �1 11 y CASINGORTIIBING th�meldefied-fee
Well CoushwAionPermit& � 2 1 01_5) l�taM To Draw I Ttncta4lss bULTERTAAL
List alJappJfcuSleweli constnrciton permi�s(fa U,fC,Cormty,SYate,Varimue,etG} $.. L
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3.Well Use Wie&well use): ft. lo.
Water Supply Well: "17.9C IMN
Al �M cipaUPablJo FROMxo etoa,ss mnmssxmt
{lecthertnal(Hesting/Cooliug Supply) Ofesidential Water ftply(single)
dustrial/Commerchd DReddendel Water Supply(sbared) ISO
Irri ation FROM To aYATERIAL EMNAt MMMEXEIDD&AMOUNT
Non WaterStlpplyy Wet1: it. � ,,
Monitnrittg
fteefiou Well:
ft. ft.
AquiferRadun e . �CuossndwaterResnediation 39:8!lt11Df�VEGPACff if
IAqUlfbrSWVand RecoverySalinityBarrier intoM To - NtATmtrnr, soePLAesatsrernesrsoD
Aquifer Test fL ft:
h�epedmental TechnoIo�► DSubsidence Control IL iL
Geothermd(Closed Loop) 07racer AID LOG:affaehi dditlonal4mis f
Cleothennal eatiog/Ceolin Return Ocher fain ander21 Remadcs) FROM TO DsscRsrrcox miu saran soSlfiodt sia.e�e
t !ter!
4.Date Wells)Completed: -Z ell ID# ft.
53. lion. .-
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FaclliWOwnerName Faclf_ityM#(ifapplfmble) %
t09- 07 s C ft.
AhysieaiAddress.C4ty,andZip 2-7 R' ft, j, 5
��tY ParcrlIdenti$cati�No.(PII� I sK21$Od
6b.LatRude and longitude in dagrwgrainntwiseconds or decimal degrees:
(if well field,one latiloag is sufficient) 22.Certification: i
LZ
6.78(me)the well(s) ..Permanent or Temporary l ofCuffiedWett r naza
By rig 1 thfs farts,IO hereby r�tiy thatthe wells)ryas(wem)constructed In nrcondance'
7.Is this a repair to an esdstmgwell: Yes, or Yp wtticISANCAC 02G.OI00 orISRNCACOZC.4200WeTl ConstructimeStnndards middwra
Ifrhls is arep 4o."owla-=wet aonmuatan infarmarloaand exprorna enanrteofthe ropYa thisnecardhasEe�provfdedtotheweito�vner.
repafrmtder#2l remarlssecllon ores iheEackafJfiis form. �3.Slte ditlgt�nloPedrlitlDn81 WCildetaily:
S.For GeoprobelDPT or Clesed•Loop Geothermal Welts haviug thesame You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed ate,indic TOTALNMSE R of-welts construction detat'Is_.Yon may also attaeh additional pages if necessary.
drilled: � �9 `o � t17BliR1'i°t' T'INC7'R'iTL'�'F�lV3
Total well depth below land surface:_ 00 248.For All Wets: Submit,ibis form within 30'days of completion of well
Formalttple wept list aUdepths YdWffent(emmpre-3@200'and201005 cqnstmationto1he following:
10.StatiewaterlevelbelowtupofeashW Z 00 DIvlsionofWhterRewurces 7nformati0aPtucesskRUnit.,
lfwaterlevdis above msing,vse"a-" i
1617 Mall Bervip CenterrRateigh,NC17693L1617
11.Borehole diameter. (119 .�1 (in)' 24b.For Intectfon Well: In addition to sending the form to the address in 24a
12.Wellconstrucdonrnethod:_ a O�t9 eve,also submit one copy of this fora within 30 days of completion of well
constructionto ttie following:
FOR WATER RULY WRW ONLY DivislonofVPaterR�esourew,Undergroundrneleetion.Control progmm3,
�/r3eMall&rvtceCenter,ltelukb lgC27SX16M
13a.Yield(gpm) Method of test:&D J-1, W For Water SHDDIv Sc Zniection Wets: III addition t0 sending the form to
the address(es) above; also,submit one copy of this form within 30 days of
13b.Disinfection tfpe: Asnonat: ��to ��r c completion of well construction to the county health department or the county
vuhele cansttucted. f
FormGW-I North CardbanDepenmentaf'EnVi n==tal WAY-DivisiMofWBtmResaetces Revised2-222016