GW1-2022-07366_Well Construction - GW1_20220808

Jan. 29. 2018 10:58AM Env. Health . No. 6711 P. 1_
WELL CONSTRUCTION RECORD(OW-1) For Internal Use Only:
].W=Contracto Informatlt>� <�l
WellConttaa"mmc SROM To �oesCnmmx -
'Sft 3/o ft.
NC Welt Coanac or Certification NumberI f;Olift lI frYS4Yfi:tdltr3iin(easid weII9:OIkLIlVEfI f Me ' .f`ro,,,
C� 4 FROM TO f7MIKETHR, THICICIESS MATERI"0
Ca . /3 s -
II4N1,R: LYIitOR".rUD1NG?""therivil:cToitid:Riid �.4.4r�;::r.�-k,:t.=<
2-Well COJ13" HOuPermits. FROM TO I WAR= I IMCKNEEs MATFdUdt.
/,ttrnlf opplirabtew•dl rarutnrerionpermlts(t e.UIC,Cmotry Stare,Yorrnnce erF)
3.Well Use(cheekwell use): rt. R, tn.
Water Supply 1Ve11:
PIt4,f Yp DGMETCa SLOTSITE T4ICKNPSS MATrAUL
Agricultural nm icipavpablic 0 2 ft.
in,
Geothermal(Seating/Cooling Supply) esidential Water Supply(single) R. /t is
IndustrieUCammcoeiol 13Residential Water Supply(sharcd)
Ifli Lion FROM T MA L LNMACLMVff R• 0UXr
Non-Water Supply Well:
Monitoring ❑Recovery n, tr.
Injection Well: 1L ft,
Aquifer Recharge OGroundxmter Remedistion
7A:�iLL'VI)/GRAiBIiPA ' Far" l+itilb==-=�;;_•'-�-.u•. ..•..—"
Aquifer Storage and Recovery OSaliniry Barrier TRO51 TO MATERIAL, W?(A RW0D
_AquiferTest QStotmwater Drainage m fr.
Experimental Technology C}Subsidence Control 2 ft
Geothffwdl(CimedLoop), Tracer s3hp tSIAG'aired;:ddleau.iiAe'etrQi(e'�isv-*- _ -
_ Geothermal(Reating/CoolingRetum) MOther eX lainuaderKi Remarks n(IM To OFSCnIPr10N calcr,hndnev.salYmtk i ,Qe elr�
4.Date Well(s)Completed:4 d d ytre►i,rni Ye/ n
/Sa.Well Locations. y h � n 6.!
4ill=- ��
Facility li0mofName Facility 1D!(itaypiimble) h R. ' ( 8NVU
phy.iea JU&nSs,City,add rip T a ! G to n. t t , +o
,
County Parealldemifi No.(FM)
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees: C
(irwellfield,one lar/iong- sa6ieieat) / ILCertiGeation:
��
6.Is(are)The wells) PtMoutnt or [Temporary Signore o ertified Wen Connector Erato
By sipTing dds Joan,I hereby cero ther the wells)r at(Mere)twu/nrered r)i aocordence
7.Is ibis a repair to an existing weft: QYes or QNo wdh]$ANCAC 02C.0100 or iJR NGiC 02C.0200 R'eg Coarrnwoon StandaxG and lhai a
((rlrlslrarepair JlOour bwmt,cdl eo run aian infarct aon mtdeaplaat thenalaro ofdta eopyofrhls meord hos teen podded rotheivell outer.
rtpmr order eel mv=6 rerdon ar on Aa back of ft form. 23.Site diagram or additiona(xdl details:
8.For Gtoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only i GW 1 is needed. indicato TOTAL.NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: j 00 249. For Ail Wells: Submit this form cvitllin 30 days of completion of well
For mulaplo sells ltrt&11&p&FfdiJf mns(exe.1de.1@2 f 2@100) construction to the following:
10.Slade crater ltvei below top of casing: r� ) 00 Division of Water Resources,Informallon Processing Unit
f1wmerleveitsabmfrcft&we"+^ 1617 Nhil SeMce Center,Raleigh,NC 2709-1617
11.Borehole diameter. 10 '/,-z (In.) 24D.For Iniecllon\Yetis: ht addition to setsdnsg Rive 6ormto the address in 29a
12.Well construction method: Y,Ith above,also submit one copy of this ibmt within 30 days of completion of well
(f.o.mgcr,mlary.cable.&sect puck ales) construction to the following: .
i
Division of Water Resources;1116cittgroand injection Control Program,
FOR WATER SUPP Y WELLS ONLY: 1636 Mail Sorviro Ceatck.Raleigh,NC 27699-1636
e
13a.Yield(gpm) Z Method of test: �. 24c.For Water Sulmly At Intecllton Wells: in addition to sending the form to
the addmss(es) above, also aubmitt one copy of this form within 30 days of
]36.Disinfection type: !1 Amount: G completion of well construction to the comity hcaith department of the county
where constructed. i
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Form Gw-1 North CamfineDepanmaw atEav roameanl Quality-Division of Water Rwomees RwAsed 2-22-2016'