GW1-2022-07753_Well Construction - GW1_20220819

Jan. 29. 2018 10:58AM Env. Health No. 6711 R. 1i
WELL CONSTRUCTION RECORD(GW 1� For Internal Use Only:
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Well Contractor Name 00114 To DESCRIPTION Y:
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NC well Co Certification Number i ec WH3 GV Etf'CASLYii:foisON _ ..lb:ORbRYEIt f- Atb " ^:"1,o �:
FROM 11 ntAMerER retcictFss TraWL
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2.Well Constraenon permit IV: 0 FROM TO VIAM M TRECtavW sreTERtai
lfsroilopplicablexeAwr cdwpent#-a tIiC.Comrry.Some,Yalaace,arc..) R. R. lo.
3.Well Use(ebeckwell use): n• h. Im
ifirrigation
ater Supply Well: �12:tit?1tBF1L¢_���_�.0
Im To DIAMETER SLOTS= ThIM- MATERIAL-
Agricultural QM icipal/Pnblic fr. ft. ia.
G.wh►rmal(13eating/Cooling Supply) esideatial Water Supply(single) tr. IL
IndustrWCommanciol bResidentiai waterSupply(Shared) --:PROM TO MATERIAL AIPLACPMPrrX nn AMOUNr
iYon-Water Supply Well tr. ra l
Monitoring DRecovey IR ft:
Injection Well:
Aquifer Reebargo 0Groundwnter Remedistion
194AVVIGROBEFAM Fii'"'ttaftil'
AquifcrStorageandRecovery DSalinityHa Tier Rmt To MATERIAL --- I EMLACURNI'M]"1110D •r
Aquifer Test I -j]Stom►W9ter Drainage & fr.
Experimental Technology 0SUbsidenceConnol m it.
Geothermal(Closed Loop):- �Traeer s 2RA
_Geothermal(Hcating/CodliniRetura) LjOther lain unda#2l Remarks FROM TO t►FaeuaPr[ox ten6.rdnerQ.satl%se�s ds
4.Date Well(s)Completed: of Well W# / p 11 ft
5a.Well Location
2 Qcl g�j� wr�rF�/�S a n
Faa7iryllhvturNaou Facility log(itipplicable) n' n'
a2 l�a _
11hricet a&-;Gtr,adZia a --»: `.
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:tip ,_....._..- _•_--- .Yn--=
Coaaty pmoel lAi'M.Mewiaa No.(PiN)
Sh..Latitude and lonifimde to degreealmiautesliecon)ds or decimal degree: J 6�
(irwall J� Id.one avlog is sufficient) /Gnl t� 22 Certification: p�,V Ig-
7fd d N W
6.I3(are)1hewetl(3) Permanent or OTempor2ry Sigmttato tttiBedWdlContracror Dale
By aismng rlds farm.I A-Ay 6[rt Jj ff-the fnell():Pas 6rere)eofulmered ai aowMaece
7.IS this a repair to an existing weu: OYes or No wdh 1SANCAC 01C.0100 or iJA NGtC OIC.0100 We/l CoAft tx ion SmMprde and that a
IfiNs Is a repel,fit!ord,iuownwdr camin crionhfma otion andaeplam the r itim ofihs copyofthis nicoMhot been protI MM thewe0 owner:
repair umfor e]1 rearesls sauion or on the Aackaffhtsfomr. 23•Site diagram or additionaf well delalls:
S.For GeoprobelDPT or Closed-Loop Geoffmajal Wells having the same You may osc the back of this page to provide additional well site details or well
construction,only i GW 1 is needed.Indicate TOTAL,NUMBER of wells eonsttuctiondetails.You may also attach additional pages if rumesvary.
dulled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land sorfaec: O J p1) 249. For All Walla: Submit this form wi0tin 30 daps of completion of well
Formulaplawenrla:rarldepduJdtfJerenrfemmple.3�100andl®if00) construction to the following
10.Staftc water level below top of casing: �! (a) Division of Water Resources,Information Processing Unit
/fvarer level rs above au&e use+" 1617 Mail SoMce Ccbhr,Raleigh,NC 27699-1611
11.Borehole diameter. pn.)
24D.For Infection Well In addition to sertdiffg the faun to the address is 2Aa
p I, above,also submit one copy ofthis That Within 30 days of completion of Well
12.Well construction method: rIt construction to the following:
(i.c.auger,miary.table,ducat push,eto.)
Division of Water Resources,Uudetground injection Control Program,
FQR WATER SUPPLY WELLS ONLY: 1636 Mad Service CQ&.Raleigh,NC 27699-106
c
13a.Yield(gprn) J G Method of tesC . 24.For Water Supply Br Injection Wells: In addition to sending the Iota to
/� ` the address(es)above, also submit one copy of this form Within 30 days of
13b.Disinfection type: Amount:Amount: 3 completion of well consttuctioti to the county health department of the county
where eonsimcled- r
FormGW-1 NonaChmfi nDgnrsmmtafEdam mearalQmlity-DivisionofWoterRcsomtcs Revised2-22-2016'
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