GW1-2022-07242_Well Construction - GW1_20220805

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WELL CONSTRUCTION R1ECM LGw-11 For Internal use only.
1.Well Contra Information:
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2.Well Condnu:doa Pert#' PAe, FIMM To I D'AMeMIL I THJCK M I MATERIAL
Lid all oppllcabk WA construction permar r a UIC,Count',state Part&=eta) n
3.Wed Use(cheek well one): R. % is
Water So"WeU; :17:SCRSFTI•;:t ?'.a'�� $C i. c,.:i_.•.�_�;: n
mom TO DIAMETrA1, SLMSM MATERIAL'..
Agricultural. [3MunicipaUPnblic eft' d n im .L q-0 (fG
Geothermal(Heating/Coolmg Supply) [Residential Water Supply(single) g, n -
Tndas>ziaUCommercial Mesidential Water Suppy,(shy) -_.;• .I, w:- sy:_
mom TD MATEItIALt ,• '`EMW.ACEMENr MSrtDD&AMOUNT
Non-Water Supply-well: 1 R n .Qyi aH. 6G �2
Monitoring Recovery ft n`
b jectioa ell:
AquiferReeharge QGmuadaarerRemediation I9.8ANIA1GRi► PACK ' -=cr -.'# "°: -;t::xv
Aquifer Storage and Recovery o5almity Barrier FROM To lrlATF1tIAL EMPLACUA NI on
Aquifer Test 13StormwaterDrainage 5"n (�(� ILak aa-re
Experimental Teebnology ❑i Sulmdeuce Control It. n
Geothermal(Closed Loop) [Tracer '20.'lr 3 Oi' atYaci lades
Geotitermal eatinF)Coolin Rcittm . Other hlin trader#Z1 Remadcg FROM To D nor rob, rotrmra as
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4.Date Well(s)Completed. 7:1 L --12�Well M#
Sa.Well Location.* 3 D e r' G n' �`" 9 V
AUG 6'2@22
Facility/Ow merNataa r Faei1M#itfapplicable) >��. t tl4 )'
�� �tc� ,t 2ii �� 2f 6C G n n In fana ion Arac.,>�sV DR
PhVS1W Address,City,sad 4 ft. tt
T,4�Ge ZI.RSSf;ARi�B'. 'Y?,can:t. •� - t,:'t',w'.`.�� •:i.,,, _ •�,-. c:i,r,.,
co"- Pared Identification No.(PIN)
5b.Latitude and longitude ID degreeslmlmutedsecoods or decimal degrees: it
(ifwdlfield,ono lWbagis suffcicut) 22.Certification:
7� N `7 7. cap
6 ia(are)The wells 1'ermaaeat or 3 empvrary _ turz.
By signing A&tarok,I hereby cniyy that the w H(s)was(were)contracted in accordance
7.Is this a repair to as eating well: [3Yes or Jallo wdk JSA NCAC DIC.0100 or IJA NCAC 02C.0200 Well Construedon Standards•and that a
.(/this it a rgwtr.fd1 out known well eommiction informadba and crplain the insure of the ropy of this record has been provided to the aril oer.
repair under#21 remark section or or the ba&of thirform. ' wn
23.Site diagram or additional well detttlls:
S.For GeoprobelDP1'or Closed-Loop Geothermal Wens Laving the same. You may use the back of this page to'provide additional well site details or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of walls constuction details, You may also attach additional pages if necessaty.
drilled;- SUBItU TAL[NSTRQGT[ONS
9.Total well depth�below bnd aosac®: � P
(fr-) 24a.For All wells: Submit this f{im within 30 days of completion of well
For mufrple wvlir list all dep9u ffdlBereat(Aample-3@20Wand 28100� i
construction to the following.-
10.Static water level below top of easing: a UP Division, Water Rancor ,IInformation Processing Unity
Ifuut.,kvd b above casting,use'+" 1617 Midi!Service Center;Raleigh,NC 2769¢1617
11.Bortbah diameter-.�_.6 (in.) 24bh For infection wells: In adtirti n to sem mg the torm to the address in 24a
above,also submit one copy of this Corm within 30 days of completion of well
12 Well eotutrnttiom method: �, ) al'(/
(Le.suge,rotary,cable,direct pusb,cm.) T construction to the following:
Division of Water Resourccs,Uodergmmd Inf ection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield Was) ]Method of test: �(r/ 24c.For Water fiunaly A lni 'oa WeBst Ja addi gm:o&%xAvg Site dam Its
the addtws(es) above, also submit one copy of this form within 30 days of
73b.Disinfection type: IJUh��` Amonai 74 f completion of well construction to the county health dcpartmant of the county
where constructed. If 4